Belmont Village Aliso Viejo.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA delivered an amended report from case management visit on 05/08/2026. Exit interview conducted and a copy of this report was left at the facility.

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to Belmont Village. The purpose of today’s visit was to conduct the required 1 year inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 180 non-ambulatory residents of which 35 may be bedridden. Facility has an approved hospice waiver for 35 residents. There are 10 residents on hospice during today's visit. The facility has 147 apartments with 46 units for memory care. Administrator Rosa Ayala has an administrator certificate expiring on 10/23/2026. Upon entry, facility appears clean, safe and sanitary. LPAs Lyman and Mendivil along with Building Engineer John Lachey toured the facility at 9:40 AM. LPAs toured the physical plant, checked food service, reviewed files as well as reviewed medication administration. LPAs toured the memory care unit as well as assisted living. The main kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen and temperatures were in compliance. LPAs observed menus in the main dining room. Residents order off a menu and facility has daily specials for variety. There is an auxiliary kitchen and dining room in the memory care unit as well as a bistro in the assisted living. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPAs pulled emergency cords and staff response was immediate. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Ten resident bathrooms were tested for water temperature and water temperature measured between 113 and 118.4 degrees F in tested bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Smoke/carbon monoxide detectors are hardwired and facility has sprinklers. CONTINUED ON LIC 809C DATED 02/19/2026 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPAs observed documentation of last fire inspection dated 07/08/2025 conducted by West Coast Fire and Integration. Smoke detectors are monitored through an electronic monitoring system, alerting staff when there is any issue with a smoke detector. Fire extinguishers were fully charged. LPAs reviewed the emergency disaster plan as well as documentation of monthly fire drills with the last drill conducted on 01/30/2026. Facility is equipped with a generator. Facility provides daily activities in the form of exercise, games, and outings in the community. LPAs toured the outside grounds and observed a locked, alarmed pool as well as ample shaded seating for residents. Facility has a theater as well as a hair and nail salon. LPAs reviewed ten resident files and six staff files. Resident files reviewed contained required documentation including physician reports, admission agreements, and resident appraisals. Resident files reviewed contained required documentation including criminal background clearance, personnel record, required annual training, and health screen/TB. LPAs reviewed medication administration and storage. Medications are stored in locked medication carts. Medications appear to be administered per physician order. LPAs observed the first aid kit contained all required items. No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 02/04/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. LPA observed medications are secured. Licensee has complied with the POC. Licensee has been advised to maintain all areas of facility in compliance. Exit interview conducted and a copy of this report was left at the facility.

Resident shares a room with the resident's wife. Resident stated that upon admission, resident shared a queen bed with wife in the facility apartment. A few months later the resident's wife needed a hospital bed and the resident donated the queen bed to charity without informing the facility. Resident indicated pressure from facility to utilize another bed and resident refused. Last week, resident obtained a bed from the facility and LPA observed the bed in the resident's room. Per physician report dated 09/27/2023, Resident is independent and making own decisions. Based on record review and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.

Licensing Program Analysts (LPAs) Kimberly Lyman and Michael Tea made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director (ED) Rosa Ayala and explained the reason for the visit. The facility is a three story building which consist of 30 units on the first floor reserved for memory care residents, and 16 additional units on the second floor for memory care residents. The capacity of the facility is 180 non-ambulatory and a hospice waiver for thirty five and bed ridden waiver for thirty five. There are currently a total of 117 residents, forty two of them are in memory care, and eleven on hospice. Rosa Ayala's Administrator's Certificate expires on October 23, 2024. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted by the resident mail box. The PUB 475 poster posted is 20" X 26." Around 9:49 AM, LPAs and ED Ayala toured the facility. LPAs observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPAs and ED toured resident rooms on three floors of the facilities. LPAs and ED toured the resident rooms in memory care unit area. LPAs inspected twelve resident rooms. All resident rooms had the required furnishings. All resident bathrooms were clean and operational. LPAs tested the emergency pendants and observed the staff came promptly when alerted. The hot water in the twelve resident rooms inspected measured 112 degrees Fahrenheit to 118.2 degrees Fahrenheit. LPAs observed residents participating in exercises in the activities room in the memory care area. There is fitness room and activities room for all residents. There is an outdoor courtyard for residents to sit outside. In the outside area there is a garden for residents to plant things. Also there is a pool area with a gate. Residents can utilize the pool as long as they are accompany with a staff who is water safety certified or a family member. In the summer they have water aerobics. There are fire extinguishers on every floor and all fire extinguishers are fully charged. LPAs observed emergency evacuation chairs in each stairwell. The last emergency fire drill was conducted on March 13, 2024. The fire safety system is inspected annual every year by an outside agency, the last inspection was 9/19/23. Around 11:10 AM after the facility tour, LPAs reviewed twelve resident files with no discrepancies. All resident files had the required documents. Afterwards LPAs reviewed ten staff files with no discrepancies observed. Annual Report cont on LIC-809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 All staff files reviewed had current CPR/First Aid training. At around 2:30 PM, LPAs inspected medication and medication administration records (MAR) for selected residents. No discrepancies observed. LPAs observed medications are kept secured in a medication cart that is locked in a medication room. LPAs observed the first aid kits to have all the required components and a first aid book at hand. LPAs interviewed staff and residents. No obstacles or hazards were noted inside or outside of the facility. Based on the observations made during today's visit, no deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided

Per the video obtained, R1 can be seen knocking the screen out of the window and climbing halfway out the window. R1 then climbed out onto the small ledge beneath the window and turned around to jump to the ground. At approximately 6:41 PM cameras observed a shadow seen falling out the side of the building. At approximately 6:53 PM a staff member found R1 lying on the sidewalk below their bedroom window. Resident records obtained did not note R1 had a history of suicidal ideation. Interviews with five of seven staff reported R1 had a history of wandering and attempted elopement. Orange County Coroner Report lists R1’s cause of death as Hemopneumothorax, Rib Fracture and Traumatic fall. Per facility policy, windows in the facility memory care are fixed to open no more than eight inches to allow fresh air into the rooms for residents. All exit leading doors are equipped with auditory alarms and delayed egress to alert staff of attempted elopements. Although R1 sustained a traumatic fall resulting in their death, a review of records obtained and interviews conducted determined that R1’s injuries were not sustained as a result of neglect by the facility staff. Evidence obtained indicates more than likely that R1 was unaware of the consequences of their actions and likely fell while attempting to leave the facility. Therefore, based on interviews conducted and documents reviewed, the allegation that staff failed to provide care and supervision which resulted in resident sustaining injuries during elopement is deemed Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report and confidential names list was left at the facility.

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 11/07/2023. LPA were greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87464(f)(4) pertaining to Basic Services has been cleared. Licensee provided proof of correction. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87464(f)(1) pertaining to Basic Services has been cleared. Licensee provided proof of correction. Licensee has complied with the POC. Licensee has been advised to maintain all areas of facility in compliance. Exit interview conducted and a copy of this report was left at the facility.

During interviews conducted with Staff 1 (S1) it was reported that the kitchen has not received complaints regarding incorrect food orders and when there has been a complaint, it has come from a resident with cognitive impairment. Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with ED Ayala, and a copy of this report was provided to the facility. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 six minutes and fifty-four seconds. Per Resident 1 (R1) staff are helpful, do their best and assist in a reasonable time. Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. LPA Ramirez conducted an exit interview with ED Ayala, and a copy of this report was provided to the facility.

Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason made an unannounced case management visit to follow-up on an incident report received by Community Care Licensing on 6/21/2023. LPAs met with Executive Director (ED) Rosa Ayala and explained the reason for the visit. Incident report dated 6/21/2023 indicated that on 6/13/2023 at about 3:00 a.m., Staff 1 (S1) and Staff 2 (S2) reported to Staff 3 (S3) that Resident 1 (R1) had redness to their back side. S3 assessed resident, they was able to move extremities with pain, and reported a 3 on a 1-10 pain scale. Resident stated he fell but could not recall details or timing. Primary Care Physician (PCP) was contacted via email and community was advised to monitor. During interviews, ED stated that on 6/13/23, R1 had one episode of vomiting and that was also reported to PCP. A record review of emails dated same date, confirm PCP was notified and inquired whether R1 was able to take a deep breath without severe pain. Staff 4 (S4) confirmed via email that R1 was able to take a deep breath without severe pain and was also “able to walk to lunch just fine” and ate breakfast and lunch with “no more episodes of throwing up.” Per ED, R1’s Responsible Party (RP) was contacted by phone, and a general voicemail was left. RP did not return facility’s call and facility staff did not make an additional attempt to contact RP. On 6/17/23, R1 was picked up for an outing with family. During outing discoloration was observed to R1’s lower back on right hand side. Family took R1 to urgent care and it was determined R1 had sustained rib fractures. During today’s visit, LPAs were unable to interview R1. R1 has not returned to facility following urgent care visit. LPAs interviewed four residents and four out of four were unable to recall observing or hearing R1 fall, and stated they had no concerns regarding falls or staff. Residents are able to call for help with a pendant or pull cord in their bedroom, should they need assistance. Per residents, staff is responsive to their needs. (Cont. LIC809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPAs reviewed and obtained pertinent documentation such as R1’s Physician Report (LIC 602) dated 6/06/23, progress notes for R1 dated 6/6-18/23, email correspondence between facility staff and PCP on 6/13/23, and a picture of R1’s injury taken on 6/13/23. LPA Gutierrez also obtained contact information for S1, S2, S3, and S4 who were not currently present at the facility to be interviewed. LPAs informed ED that subsequent visits and document requests could be required regarding the incident and ED stated they understood. An exit interview was conducted, and a copy of this report was left at the facility.