Inspection Reports for Belmont Village Senior Living Aliso Viejo
300 Freedom Ln, Aliso Viejo, CA 92656, United States, CA, 92656
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance. However, there have been some serious issues in the past, including medication errors, failure to provide timely medication and oxygen leading to a resident’s death in November 2023, and a substantiated incident of medication record falsification in April 2022. The facility also had a substantiated complaint in July 2022 involving a resident eloping without staff awareness, posing an immediate health and safety risk. The most recent report from February 20, 2025, showed one minor deficiency related to centrally stored medications, which had been corrected from an earlier citation. This suggests some improvement over time, with recent inspections showing fewer and less severe deficiencies than in prior years.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
74% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Census: 133
Capacity: 180
Deficiencies: 1
Feb 20, 2025
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced Plan of Correction visit |
| Rosa Ayala | Administrator/Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Capacity: 180
Deficiencies: 0
Feb 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding staff training on dementia care and ensuring residents take medication.
Findings
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.
Complaint Details
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.
Report Facts
Facility capacity: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Evaluator / Licensing Program Analyst | Conducted the complaint investigation visit |
| Fred Arias | Licensing Program Analyst | Assisted in conducting the complaint investigation visit |
| Rosa Ayala | Administrator | Facility administrator met during the investigation |
Inspection Report
Annual Inspection
Census: 134
Capacity: 180
Deficiencies: 1
Feb 4, 2025
Visit Reason
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.
Findings
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A bottle of acetaminophen was found in a resident's medicine cabinet despite the resident's physician stating the resident cannot self-administer PRN medication, posing an immediate health and safety risk. | Type A |
Report Facts
Residents in memory care: 46
Residents on hospice: 14
PRNs observed in bathroom: 1
Resident rooms inspected: 12
Staff files reviewed: 5
Hot water temperature range: 112.4
Hot water temperature range: 117.3
Plan of Correction Due Date: Feb 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosa Ayala | Executive Director | Met with Licensing Program Analysts during the inspection and named in the report |
| Fred Arias | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection |
| Alisa Ortiz | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 180
Deficiencies: 0
May 6, 2024
Visit Reason
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.
Findings
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.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.
Report Facts
Facility capacity: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Rosa Ayala | Administrator | Facility administrator met during the investigation |
Inspection Report
Annual Inspection
Census: 117
Capacity: 180
Deficiencies: 0
Apr 30, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted by Licensing Program Analysts Kimberly Lyman and Michael Tea to evaluate compliance with licensing regulations.
Findings
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.
Report Facts
Residents in memory care: 42
Residents on hospice: 11
Hot water temperature range: 112-118.2
Fire drill date: Mar 13, 2024
Fire safety system inspection date: Sep 19, 2023
Administrator certificate expiration: Oct 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosa Ayala | Executive Director | Met with Licensing Program Analysts during inspection and named in report |
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection |
| Michael Tea | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Capacity: 180
Deficiencies: 0
Mar 20, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Facility capacity: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Rosa Ayala | Administrator | Facility administrator met during the investigation |
Inspection Report
Plan of Correction
Census: 115
Capacity: 180
Deficiencies: 2
Nov 29, 2023
Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection based on deficiencies cited in a prior inspection report dated 11/07/2023.
Findings
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.
Deficiencies (2)
| Description |
|---|
| Deficiency cited under Title 22 Regulation 87464(f)(4) pertaining to Basic Services |
| Deficiency cited under Title 22 Regulation 87464(f)(1) pertaining to Basic Services |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced Plan of Correction visit. |
| Rosa Ayala | Administrator | Facility administrator met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 180
Deficiencies: 1
Nov 29, 2023
Visit Reason
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.
Findings
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.
Complaint Details
The complaint alleging failure to provide resident's records to authorized representative was substantiated based on evidence reviewed and interviews conducted.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide resident's records to authorized representative within required timeframe. | Type B |
Report Facts
Capacity: 180
Census: 115
Deficiencies cited: 1
Plan of Correction Due Date: Dec 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rosa Ayala | Executive Director | Met with Licensing Program Analyst during investigation |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 180
Deficiencies: 2
Nov 7, 2023
Visit Reason
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.
Findings
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 Details
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.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure Resident 1 was assisted with medication as prescribed, resulting in lack of pain management at end of life. | Type A |
| Failed to ensure care and supervision including continuous oxygen administration as prescribed, with oxygen turned off on two occasions. | Type A |
Report Facts
Facility capacity: 180
Resident census: 115
Deficiency count: 2
Plan of Correction due date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rosa Ayala | Administrator / Executive Director | Facility administrator met during investigation and exit interview |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 180
Deficiencies: 0
Oct 11, 2023
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Number of individuals interviewed regarding food service allegation: 10
Average response time to call assistance button: 15
Tested response time range: 3.34
Tested response time range: 6.54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation and exit interviews. |
| Rosa Ayala | Executive Director | Facility representative met during the investigation and exit interview. |
Inspection Report
Follow-Up
Census: 104
Capacity: 180
Deficiencies: 0
Jun 29, 2023
Visit Reason
Unannounced case management visit to follow-up on an incident report received regarding a resident's injury and related care.
Findings
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.
Report Facts
Facility capacity: 180
Resident census: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosa Ayala | Executive Director | Met with Licensing Program Analysts during visit and provided information about the incident |
| Claudia Gutierrez | Licensing Program Analyst | Conducted the inspection and documented findings |
| Dwayne Mason | Licensing Program Analyst | Conducted the inspection and documented findings |
Inspection Report
Follow-Up
Census: 109
Capacity: 180
Deficiencies: 0
Nov 29, 2022
Visit Reason
Unannounced case management visit to follow up on an incident report received regarding a resident fall on 11/21/2022.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosa Ayala | Executive Director | Met with LPAs during the visit and involved in resident assessment follow-up. |
Inspection Report
Plan of Correction
Census: 109
Capacity: 180
Deficiencies: 1
Nov 29, 2022
Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection based on deficiencies cited in a prior inspection on 2022-10-19.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Deficiency cited under Title 22 Regulation 87468.2(a)(1) pertaining to Personal Rights |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the Plan of Correction visit and observed compliance. |
| Alvaro Ramirez | Licensing Program Analyst | Conducted the Plan of Correction visit and observed compliance. |
| Rosa Ayala | Administrator | Facility administrator met with Licensing Program Analysts during the visit. |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 105
Capacity: 180
Deficiencies: 1
Oct 19, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on the facility's enrollment in the "Safely You" program.
Findings
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents are afforded privacy; no video surveillance signage posted and not all consents required for camera usage obtained. | Type B |
Report Facts
Consents for camera usage: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Alisa Ortiz | Licensing Program Manager | Named as supervisor and licensing program manager |
| Rosa Ayala | Administrator | Facility administrator met during the visit |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 180
Deficiencies: 1
Jul 15, 2022
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to ensure resident was provided care and supervision; resident eloped and staff were unaware, posing immediate health and safety risk. | Type A |
Report Facts
Capacity: 180
Census: 99
Civil penalty: 1
Plan of Correction Due Date: Jul 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Rosa Ayala | Executive Director | Facility administrator met during investigation and named in findings |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 180
Deficiencies: 1
Jun 21, 2022
Visit Reason
Unannounced case management visit to follow up on an incident report received regarding medication administration errors involving two residents.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to ensure care and supervision was provided to R1 and R2. R1 received no medication on June 7, 2022 and R2 received R1's medications, posing an immediate health and safety risk. | Type A |
Report Facts
Hours of shadowing completed by Staff 1 prior to incident: 16
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosa Ayala | Executive Director | Met with Licensing Program Analyst during the visit and discussed the incident and findings. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report. |
| Alisa Ortiz | Licensing Program Manager | Named as supervisor and licensing program manager in the report. |
Inspection Report
Census: 99
Capacity: 180
Deficiencies: 0
Jun 2, 2022
Visit Reason
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.
Findings
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.
Report Facts
SOC 341 report date: May 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosa Ayala | Executive Director | Met with Licensing Program Analyst during the visit and involved in the incident investigation |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 180
Deficiencies: 1
Apr 28, 2022
Visit Reason
The inspection was an unannounced case management visit conducted in conjunction with a complaint investigation regarding the mismanagement of Resident 1's medication.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California, posing an immediate health and safety risk to residents in care. | Type A |
Report Facts
Census: 97
Total Capacity: 180
Deficiency Type A Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection and investigation |
| Rosa Ayala | Administrator | Facility administrator met during the inspection |
| Alisa Ortiz | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 180
Deficiencies: 1
Apr 28, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff mishandled a resident's medication while in care.
Findings
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.
Complaint Details
The complaint was substantiated based on evidence including falsified Medication Administration Records and staff interviews indicating failure to administer medication to Resident 1.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide medication assistance to Resident 1 for four days, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 180
Census: 97
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Rosa Ayala | Administrator | Facility administrator present during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 180
Deficiencies: 1
Apr 14, 2022
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure care and supervision was provided to Resident 2, who took a large amount of Tramadol located in the resident's room despite being unable to manage medications. | Type A |
Report Facts
Census: 103
Total Capacity: 180
Deficiencies cited: 1
Plan of Correction Due Date: Apr 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allan Macabitas | Director of Resident Services | Met with Licensing Program Analyst during the visit and involved in the incident follow-up |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Alisa Ortiz | Licensing Program Manager | Supervisor overseeing the inspection and cited deficiency |
Inspection Report
Annual Inspection
Census: 100
Capacity: 180
Deficiencies: 0
Feb 28, 2022
Visit Reason
An unannounced required annual visit was conducted to evaluate the facility's compliance with licensing regulations.
Findings
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.
Report Facts
Residents on hospice care: 5
Residents in Assisted Living: 62
Residents in Memory Care: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection visit |
| Rosalie Sullivan | Regional Operations Specialist | Accompanied the Licensing Program Analyst during the facility tour |
| Rosa Ayala | Administrator | Facility administrator with current certificate |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 180
Deficiencies: 1
Jun 7, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff dispensed incorrect medication to a resident.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure care and supervision as evidenced by Resident 1 being inadvertently given seven medications belonging to another resident, resulting in hospitalization for observation. | Type A |
Report Facts
Capacity: 180
Census: 76
Plan of Correction Due Date: Jun 8, 2021
Medications given in error: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Nerissa Lagmay | Administrator | Facility administrator named in the report |
| Rosa Ayala | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Colleen Papps | Executive Director | Met with Licensing Program Analyst during investigation |
| Staff 1 | Licensed Vocational Nurse (LVN) | Staff member who dispensed incorrect medication |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 180
Deficiencies: 1
Apr 13, 2021
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure S1's criminal clearance was transferred to the facility, posing an immediate health and safety risk to residents. | Type A |
Report Facts
Census: 67
Total Capacity: 180
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Logan Cooley | Executive Director | Reported the allegation to authorities and facility representatives during the visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and inspection |
| Alisa Ortiz | Licensing Program Manager | Supervisor overseeing the inspection |
| Nerissa Lagmay | Director of Resident Services | Met with Licensing Program Analyst during the visit |
| Colleen Papp | Executive Director | Arrived during the visit and participated in discussions |
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