Inspection Reports for Belmont Village Senior Living Aliso Viejo

Licensing Program Analyst Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon deficiencies cited on 02/04/2025.

The deficiency related to centrally stored medications cited under Title 22 Regulation 87465(h)(2) has been cleared. Medications were observed to be secured and the licensee has complied with the Plan of Correction.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding staff training on dementia care and ensuring residents take medication.

The investigation found the allegation that staff were not properly trained to deal with dementia residents to be unfounded, as training records showed appropriate dementia training. The allegation that staff were not ensuring residents took medication was deemed unsubstantiated due to lack of sufficient evidence, with medication administration records and staff interviews supporting proper medication administration.

Two allegations were investigated: 1) Staff are not trained properly on how to deal with dementia residents, which was found to be unfounded. 2) Staff are not ensuring residents take medication, which was found to be unsubstantiated.

The visit was an unannounced required annual inspection conducted by Licensing Program Analysts Kimberly Lyman and Fred Arias to evaluate compliance with regulations at Belmont Village Aliso Viejo facility.

The facility was generally found to be clean, organized, and compliant with required documentation and safety measures. However, one deficiency was cited related to centrally stored medications, where a bottle of acetaminophen was found in a resident's medicine cabinet despite the resident being unable to self-administer PRN medication, posing an immediate health and safety risk.

An unannounced complaint investigation visit was conducted to investigate allegations that staff did not provide an appropriate sleeping arrangement and adequate care and supervision to a resident.

The investigation found that the resident shared a room with their wife and had donated their queen bed to charity without informing the facility. The resident later obtained a bed from the facility. Based on interviews, record reviews, and observations, the allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.

The inspection was an unannounced required annual inspection conducted by Licensing Program Analysts Kimberly Lyman and Michael Tea to evaluate compliance with licensing regulations.

The facility was found to be in compliance with no deficiencies cited. The kitchen, resident rooms, medication administration, staff files, and safety equipment were all observed to be in good order with no discrepancies.

The visit was an unannounced complaint investigation triggered by an allegation that staff failed to provide care and supervision, resulting in a resident sustaining injuries during elopement.

The investigation found that although the resident sustained a traumatic fall resulting in death, the injuries were not due to neglect by facility staff. Evidence indicated the resident was likely unaware of the consequences of their actions and fell while attempting to leave the facility. The allegation was deemed unsubstantiated.

The complaint alleged staff failed to provide care and supervision which resulted in a resident sustaining injuries during elopement. The allegation was found unsubstantiated after review of records, interviews, and evidence including surveillance video and medical reports.

The visit was an unannounced Plan of Correction (POC) inspection based on deficiencies cited in a prior inspection report dated 11/07/2023.

The deficiencies cited under Title 22 Regulation 87464(f)(4) and 87464(f)(1) pertaining to Basic Services have been cleared. The licensee provided proof of correction and complied with the Plan of Correction. The licensee was advised to maintain all areas of the facility in compliance.

An unannounced complaint investigation visit was conducted in response to an allegation that the facility failed to provide a resident's records to an authorized representative.

The investigation found that the facility received a request for Resident 1's records but had not submitted the records as of the inspection date, resulting in a substantiated violation of regulations requiring prompt access to resident records.

The complaint alleging failure to provide resident's records to authorized representative was substantiated based on evidence reviewed and interviews conducted.

Unannounced complaint investigation visit conducted due to allegations that staff did not give medications timely and oxygen was not kept on resident according to physician's orders.

Investigation substantiated that the facility failed to provide timely medication and continuous oxygen to Resident 1 as ordered by hospice, resulting in immediate health and safety risks. Hospice nurses found that medication orders were not followed and oxygen was turned off on multiple occasions. Resident 1 passed away shortly after these failures.

Complaint was substantiated based on evidence that staff failed to administer medications timely and did not maintain oxygen as ordered, leading to resident's rapid decline and death. The investigation included interviews, record reviews, and hospice documentation.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-05 alleging inadequate food service and untimely response to residents' call assistance buttons.

The investigation found conflicting information regarding the food service allegation, with some residents corroborating and others denying it, resulting in the allegation being deemed unsubstantiated. The allegation regarding untimely response to call assistance buttons was found to be unfounded based on interviews and response time tests.

Two allegations were investigated: 1) Staff did not provide adequate food service, which was deemed unsubstantiated due to conflicting evidence; 2) Staff do not respond to resident's call assistance button in a timely manner, which was deemed unfounded based on interviews and observed response times.

Unannounced case management visit to follow-up on an incident report received regarding a resident's injury and related care.

The visit reviewed the incident involving a resident who sustained rib fractures after a fall. Staff and physician communications were documented, and interviews with residents indicated no concerns about falls or staff responsiveness. The resident had not returned to the facility following urgent care.

Unannounced case management visit to follow up on an incident report received regarding a resident fall on 11/21/2022.

Resident 1 fell and was initially assessed by facility LVN and hospice nurse. The resident was later diagnosed with a broken left hip after further assessment and mobile X-ray. During the visit, the resident was observed resting comfortably and pertinent documentation was reviewed.

The visit was an unannounced Plan of Correction (POC) inspection based on deficiencies cited in a prior inspection on 2022-10-19.

The previously cited deficiency related to Personal Rights under Title 22 Regulation 87468.2(a)(1) was cleared. The Licensing Program Analysts observed video surveillance signage and signed consents, confirming compliance with the Plan of Correction. The licensee was advised to maintain compliance in all areas.

An unannounced case management visit was conducted to follow up on the facility's enrollment in the "Safely You" program.

The facility was found to be non-compliant with privacy requirements under the "Safely You" program, as it lacked video surveillance signage outside rooms and did not have all required consents for camera usage, with only 24 out of 27 consents obtained.

An unannounced complaint investigation was conducted following a complaint received on 2022-06-22 regarding a resident eloping from the facility and allegations of understaffing and lack of care and supervision.

The investigation substantiated that a resident eloped from the facility without staff awareness, posing an immediate health and safety risk. Allegations of understaffing and lack of care and supervision were found unsubstantiated based on staff interviews and documentation.

The complaint was substantiated regarding the resident eloping from the facility. The allegations of understaffing and failure to provide care and supervision were unsubstantiated due to lack of sufficient evidence.

Unannounced case management visit to follow up on an incident report received regarding medication administration errors involving two residents.

The facility failed to ensure proper care and supervision when Staff 1 administered Resident 1's medications to Resident 2, resulting in Resident 1 not receiving any medications. No adverse effects were noted, but this posed an immediate health and safety risk.

Incident report dated 06/07/2022 indicated medication administration error by Staff 1. Facility investigation confirmed the error and corrective actions were taken. Physician and family were notified. Facility monitored Resident 2 hourly with no adverse effects noted.

An unannounced case management visit was conducted to follow up on an SOC 341 report received by Community Care Licensing regarding an incident involving inappropriate statements made by a staff member to a resident.

No deficiencies were noted during the visit. The facility completed an investigation of the incident, staff training records were reviewed and found current, and staff denied any abusive behavior towards residents.

The inspection was an unannounced case management visit conducted in conjunction with a complaint investigation regarding the mismanagement of Resident 1's medication.

The investigation revealed that the Medication Administration Record (MAR) had been falsified between 02/11/2022 and 02/15/2022, with facility management requesting staff to sign the MAR even though medication had not been administered. A violation was cited for conduct inimical to the health and safety of residents.

The visit was complaint-related, investigating allegations of medication mismanagement and falsification of medication records. The complaint was substantiated based on interviews and document review.

An unannounced complaint investigation was conducted in response to an allegation that staff mishandled a resident's medication while in care.

The investigation found that Resident 1 did not receive prescribed medications for four days due to medication being sent out for re-packaging at the pharmacy. The Medication Administration Record was falsified, and staff were instructed to sign the document after the fact. The allegation was substantiated.

The complaint was substantiated based on evidence including falsified Medication Administration Records and staff interviews indicating failure to administer medication to Resident 1.

Unannounced case management visit to follow up on an incident report received on 2022-04-13 regarding a resident who took a large amount of Tramadol and required hospital evaluation.

The facility failed to ensure adequate care and supervision for Resident 2, who took a large amount of Tramadol that was accessible in the resident's room despite being unable to manage medications, posing an immediate health risk.

The visit was triggered by an incident report dated 2022-04-06 indicating Resident 2 was upset and had a psychiatric issue, took a large amount of Tramadol, and was hospitalized. The complaint was substantiated by observations during the visit.

An unannounced required annual visit was conducted to evaluate the facility's compliance with licensing regulations.

The facility was found to be clean, sanitary, and well-maintained with no deficiencies noted. Residents appeared happy and well cared for, and all required safety and health measures were observed.

An unannounced complaint investigation visit was conducted in response to an allegation that staff dispensed incorrect medication to a resident.

The investigation substantiated that on 05/26/2021, a staff member dispensed the incorrect medication to a resident, giving Resident 1 seven medications belonging to another resident. Resident 1 was hospitalized for observation but returned the same day without adverse effects. Retraining was provided to the staff involved.

The complaint was substantiated. Staff dispensed incorrect medication to a resident, which posed an immediate health and safety risk. The investigation was conducted by Licensing Program Analyst Kimberly Lyman.

Unannounced case management visit to follow up on an incident report received on 04/13/2021 regarding an allegation of inappropriate staff conduct involving a resident.

The investigation found that the staff member (S1) was not associated with the facility and lacked documentation of criminal record clearance transfer. Residents interviewed expressed satisfaction with their care and safety. A violation was cited for failure to ensure criminal clearance transfer for S1, posing an immediate health and safety risk.

The visit was triggered by a complaint alleging that Staff 1 put their hand in a resident's underwear. The allegation was reported to Community Care Licensing, Ombudsman, and Orange County Sheriff. Deputies interviewed the resident but did not open a case as no crime was committed. Further investigation was required.