Inspection Reports for
Belmont Village Senior Living Aliso Viejo

300 Freedom Ln, Aliso Viejo, CA 92656, United States, CA, 92656

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Deficiencies (last 6 years)

Deficiencies (over 6 years) 5.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

33% worse than California average
California average: 4 deficiencies/year

Deficiencies per year

16 12 8 4 0
2021
2022
2023
2024
2025
2026

Census

Latest occupancy rate 73% occupied

Based on a February 2026 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy over time

40 80 120 160 200 Apr 2021 Apr 2022 Jun 2022 Nov 2022 Nov 2023 Feb 2025 Feb 2026

Inspection Report

Annual Inspection
Census: 131 Capacity: 180 Deficiencies: 0 Date: Feb 19, 2026

Visit Reason
The visit was an unannounced required 1-year inspection of Belmont Village Aliso Viejo to evaluate compliance with licensing requirements.

Findings
The facility was found to be clean, safe, and sanitary with no deficiencies noted during the visit. All areas including physical plant, food service, medication administration, resident rooms, and safety equipment were inspected and found compliant.

Report Facts
Residents on hospice: 10 Apartments: 147 Memory care units: 46 Bedridden residents allowed: 35 Water temperature range: 113 Water temperature range: 118.4 Fire inspection date: Jul 8, 2025 Fire drill date: Jan 30, 2026 Resident files reviewed: 10 Staff files reviewed: 6

Employees mentioned
NameTitleContext
Rosa AyalaAdministratorFacility administrator present during inspection
Kimberly LymanLicensing Program AnalystConducted the inspection
Andrea MendivilLicensing Program AnalystConducted the inspection
John LacheyBuilding EngineerAssisted in facility tour during inspection
Alisa OrtizLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Plan of Correction
Census: 133 Capacity: 180 Deficiencies: 1 Date: 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)
Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the unannounced Plan of Correction visit
Rosa AyalaAdministrator/DirectorMet with Licensing Program Analyst during the visit

Inspection Report

Plan of Correction
Census: 133 Capacity: 180 Deficiencies: 1 Date: Feb 20, 2025

Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection based on deficiencies cited in a prior inspection on 2025-02-04.

Findings
The deficiency related to centrally stored medications cited previously has been cleared. Medications were observed to be secured and the licensee has complied with the Plan of Correction. The licensee was advised to maintain compliance in all areas.

Deficiencies (1)
Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared.

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the unannounced Plan of Correction visit.
Rosa AyalaAdministrator/DirectorMet with the Licensing Program Analyst during the inspection.

Inspection Report

Complaint Investigation
Capacity: 180 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Facility capacity: 180

Employees mentioned
NameTitleContext
Kimberly LymanEvaluator / Licensing Program AnalystConducted the complaint investigation visit
Fred AriasLicensing Program AnalystAssisted in conducting the complaint investigation visit
Rosa AyalaAdministratorFacility administrator met during the investigation

Inspection Report

Annual Inspection
Census: 134 Capacity: 180 Deficiencies: 1 Date: 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.

Deficiencies (1)
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.
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
NameTitleContext
Rosa AyalaExecutive DirectorMet with Licensing Program Analysts during the inspection and named in the report
Fred AriasLicensing Program AnalystConducted the inspection and authored the report
Kimberly LymanLicensing Program AnalystConducted the inspection
Alisa OrtizLicensing Program ManagerSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 134 Capacity: 180 Deficiencies: 1 Date: Feb 4, 2025

Visit Reason
Licensing Program Analysts conducted an unannounced required annual inspection of the facility to evaluate compliance with regulations.

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 medication being accessible in a resident's medicine cabinet, posing a health and safety risk.

Deficiencies (1)
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.
Report Facts
Residents present: 134 Total licensed capacity: 180 Memory care residents: 46 Hospice residents: 14 Hot water temperature range: 112.4 Hot water temperature range: 117.3 Plan of Correction due date: Feb 5, 2025

Employees mentioned
NameTitleContext
Rosa AyalaExecutive DirectorMet with Licensing Program Analysts during inspection
Fred AriasLicensing EvaluatorConducted inspection and authored report
Kimberly LymanLicensing Program AnalystConducted inspection
Alisa OrtizSupervisorSupervisor overseeing inspection

Inspection Report

Complaint Investigation
Capacity: 180 Deficiencies: 0 Date: Feb 4, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-02-12 regarding staff training on dementia care and 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.
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 and the staff involved was terminated. The allegation that staff were not ensuring residents took medication was deemed unsubstantiated due to lack of evidence, with medication administration records reviewed and staff and residents interviewed confirming proper medication administration.

Report Facts
Facility capacity: 180

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation
Fred AriasLicensing Program AnalystConducted the complaint investigation
Rosa AyalaAdministratorFacility administrator met during investigation

Inspection Report

Complaint Investigation
Capacity: 180 Deficiencies: 0 Date: 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.

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

Report Facts
Facility capacity: 180

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation visit
Alisa OrtizLicensing Program ManagerNamed in report as Licensing Program Manager
Rosa AyalaAdministratorFacility administrator met during the investigation

Inspection Report

Complaint Investigation
Capacity: 180 Deficiencies: 0 Date: May 6, 2024

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

Complaint Details
The complaint investigation was unsubstantiated, meaning there was not sufficient evidence to prove the alleged violations occurred.
Findings
The investigation revealed that Resident 1 was seen by home health for dermatitis and was discharged from home health on 01/24/2024. The resident wears compression socks daily as directed and is independent and making own decisions. The resident shared a room with their wife and initially shared a queen bed, which was later donated to charity without informing the facility. The resident refused to use another bed until recently obtaining one from the facility. Based on record review and interviews, the allegations were unsubstantiated due to lack of preponderance of evidence.

Report Facts
Facility capacity: 180

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation visit
Rosa AyalaAdministratorFacility administrator met during the investigation
Alisa OrtizSupervisorSupervisor named in the report

Inspection Report

Annual Inspection
Census: 117 Capacity: 180 Deficiencies: 0 Date: 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
NameTitleContext
Rosa AyalaExecutive DirectorMet with Licensing Program Analysts during inspection and named in report
Kimberly LymanLicensing Program AnalystConducted the inspection
Michael TeaLicensing Program AnalystConducted the inspection and signed the report

Inspection Report

Annual Inspection
Census: 117 Capacity: 180 Deficiencies: 0 Date: Apr 30, 2024

Visit Reason
Licensing Program Analysts conducted an unannounced required annual inspection of the facility to evaluate compliance with licensing regulations.

Findings
The facility was found to be in compliance with no deficiencies cited. The environment was clean and organized, resident rooms and bathrooms were properly furnished and operational, emergency systems were functional, and staff files and medication records showed 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 inspection date: Sep 19, 2023 Administrator certificate expiration: Oct 23, 2024 Perishable food supply: 2 Non-perishable food supply: 7 Resident rooms inspected: 12 Staff files reviewed: 10 Resident files reviewed: 12

Employees mentioned
NameTitleContext
Rosa AyalaExecutive DirectorMet with Licensing Program Analysts during inspection and named in report
Kimberly LymanLicensing Program AnalystConducted the inspection
Michael TeaLicensing Program AnalystConducted the inspection and signed the report
Alisa OrtizSupervisorNamed as supervisor in the report

Inspection Report

Complaint Investigation
Capacity: 180 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Facility capacity: 180

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation visit and authored the report
Alisa OrtizLicensing Program ManagerNamed as Licensing Program Manager on the report
Rosa AyalaAdministratorFacility administrator met during the investigation

Inspection Report

Complaint Investigation
Capacity: 180 Deficiencies: 0 Date: Mar 20, 2024

Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff failed to provide care and supervision which resulted in a resident sustaining injuries during elopement.

Complaint Details
The complaint alleged staff failed to provide care and supervision resulting in resident injuries during elopement. The allegation was investigated and found unsubstantiated based on interviews and document review.
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 likely fell while attempting to leave the facility and was unaware of the consequences of their actions. The allegation was deemed unsubstantiated.

Report Facts
Facility capacity: 180

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation visit
Rosa AyalaAdministratorFacility administrator met during the investigation
Alisa OrtizSupervisorSupervisor overseeing the investigation

Inspection Report

Plan of Correction
Census: 115 Capacity: 180 Deficiencies: 2 Date: 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)
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
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the unannounced Plan of Correction visit.
Rosa AyalaAdministratorFacility administrator met with the Licensing Program Analyst during the visit.

Inspection Report

Complaint Investigation
Census: 115 Capacity: 180 Deficiencies: 1 Date: 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.

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

Deficiencies (1)
Facility failed to provide resident's records to authorized representative within required timeframe.
Report Facts
Capacity: 180 Census: 115 Deficiencies cited: 1 Plan of Correction Due Date: Dec 1, 2023

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation visit
Rosa AyalaExecutive DirectorMet with Licensing Program Analyst during investigation
Alisa OrtizLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Plan of Correction
Census: 115 Capacity: 180 Deficiencies: 2 Date: Nov 29, 2023

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 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 has complied with the Plan of Correction.

Deficiencies (2)
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
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the Plan of Correction visit
Rosa AyalaAdministratorFacility administrator met during the visit
Alisa OrtizSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Complaint Investigation
Census: 115 Capacity: 180 Deficiencies: 1 Date: 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.

Complaint Details
The complaint was substantiated based on evidence that the facility received a request for Resident 1's records on 11/16/2023 and had not submitted the records by 11/29/2023. The investigation was conducted by Licensing Program Analyst Kimberly Lyman.
Findings
The investigation substantiated the allegation that the facility failed to submit requested resident records to the authorized representative by the date of the visit, posing a potential health and safety risk to residents in care.

Deficiencies (1)
Facility failed to provide resident's records to authorized representative, not meeting the requirement to promptly provide photocopied records within two business days.
Report Facts
Capacity: 180 Census: 115 Deficiency Type Count: 1 Plan of Correction Due Date: Dec 1, 2023

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation
Rosa AyalaExecutive DirectorMet with Licensing Program Analyst during investigation and named in findings

Inspection Report

Complaint Investigation
Census: 115 Capacity: 180 Deficiencies: 2 Date: 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.

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.
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.

Deficiencies (2)
Failed to ensure Resident 1 was assisted with medication as prescribed, resulting in lack of pain management at end of life.
Failed to ensure care and supervision including continuous oxygen administration as prescribed, with oxygen turned off on two occasions.
Report Facts
Facility capacity: 180 Resident census: 115 Deficiency count: 2 Plan of Correction due date: 1

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation and authored the report
Rosa AyalaAdministrator / Executive DirectorFacility administrator met during investigation and exit interview
Alisa OrtizLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Complaint Investigation
Census: 115 Capacity: 180 Deficiencies: 2 Date: Nov 7, 2023

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not give medications timely and oxygen was not kept on a resident according to physician's orders.

Complaint Details
The complaint investigation was substantiated. Allegations included staff not giving medications timely and oxygen not being kept on the resident according to physician's orders. Evidence showed failure to administer Morphine as ordered and oxygen being turned off on multiple occasions. Resident passed away on 01/29/2022.
Findings
The investigation substantiated that the facility failed to provide timely medication administration and continuous oxygen as prescribed to Resident 1, resulting in immediate health and safety risks. Hospice documentation and staff interviews confirmed these deficiencies, and the resident passed away shortly after.

Deficiencies (2)
Failed to ensure Resident 1 was assisted with medication assistance, resulting in lack of prescribed pain management at end of life.
Failed to ensure care was provided to Resident 1, including continuous oxygen administration as prescribed.
Report Facts
Capacity: 180 Census: 115 Deficiencies cited: 2 Plan of Correction Due Date: Nov 8, 2023

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation and authored the report
Rosa AyalaAdministratorFacility administrator met during investigation and participated in exit interview

Inspection Report

Complaint Investigation
Census: 114 Capacity: 180 Deficiencies: 0 Date: 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.

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.
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.

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
NameTitleContext
Alvaro Ramirez Jr.Licensing Program AnalystConducted the complaint investigation and exit interviews.
Rosa AyalaExecutive DirectorFacility representative met during the investigation and exit interview.

Inspection Report

Complaint Investigation
Census: 114 Capacity: 180 Deficiencies: 0 Date: Oct 11, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints alleging that staff did not provide adequate food service and did not respond to residents' call assistance buttons in a timely manner.

Complaint Details
The complaint investigation involved two main allegations: 1) staff did not provide adequate food service, which was deemed unsubstantiated due to conflicting evidence; 2) staff did not respond to residents' call assistance buttons in a timely manner, which was deemed unfounded based on interviews and observed response times.
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. Regarding the call assistance allegation, most individuals denied the claim, and response times were observed to be within reasonable limits, leading to the allegation being deemed unfounded.

Report Facts
Response time to call assistance button (minutes): 15 Response time to call assistance button (minutes): 2 Response time to call assistance button (minutes): 3.57

Employees mentioned
NameTitleContext
Alvaro Ramirez Jr.Licensing Program AnalystConducted the complaint investigation and exit interviews
Rosa AyalaExecutive DirectorFacility representative met during the investigation and exit interview

Inspection Report

Follow-Up
Census: 104 Capacity: 180 Deficiencies: 0 Date: 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
NameTitleContext
Rosa AyalaExecutive DirectorMet with Licensing Program Analysts during visit and provided information about the incident
Claudia GutierrezLicensing Program AnalystConducted the inspection and documented findings
Dwayne MasonLicensing Program AnalystConducted the inspection and documented findings

Inspection Report

Follow-Up
Census: 104 Capacity: 180 Deficiencies: 0 Date: 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 confirmed, and residents reported 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
NameTitleContext
Rosa AyalaExecutive DirectorMet with LPAs during visit and provided information about the incident
Claudia GutierrezLicensing EvaluatorConducted the inspection and authored the report
Armando J LuceroSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Follow-Up
Census: 109 Capacity: 180 Deficiencies: 0 Date: 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
NameTitleContext
Rosa AyalaExecutive DirectorMet with LPAs during the visit and involved in resident assessment follow-up.

Inspection Report

Plan of Correction
Census: 109 Capacity: 180 Deficiencies: 1 Date: 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)
Deficiency cited under Title 22 Regulation 87468.2(a)(1) pertaining to Personal Rights

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the Plan of Correction visit and observed compliance.
Alvaro RamirezLicensing Program AnalystConducted the Plan of Correction visit and observed compliance.
Rosa AyalaAdministratorFacility administrator met with Licensing Program Analysts during the visit.
Alisa OrtizLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Follow-Up
Census: 109 Capacity: 180 Deficiencies: 0 Date: 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.

Complaint Details
Visit was triggered by an incident report regarding a resident fall; no substantiation status stated.
Findings
Resident 1 fell attempting to walk 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.

Report Facts
Facility capacity: 180 Resident census: 109

Employees mentioned
NameTitleContext
Rosa AyalaExecutive DirectorMet with Licensing Program Analysts during the visit

Inspection Report

Plan of Correction
Census: 109 Capacity: 180 Deficiencies: 1 Date: Nov 29, 2022

Visit Reason
Licensing Program Analysts conducted an unannounced Plan of Correction (POC) visit based on deficiencies cited in a prior inspection on 10/19/2022.

Findings
The previously cited deficiency related to Personal Rights under Title 22 Regulation 87468.2(a)(1) was cleared. Video surveillance signage and signed consents were observed, indicating compliance with the Plan of Correction. The licensee was advised to maintain compliance in all facility areas.

Deficiencies (1)
Deficiency cited under Title 22 Regulation 87468.2(a)(1) pertaining to Personal Rights

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the Plan of Correction visit and observed compliance.
Alvaro RamirezLicensing Program AnalystConducted the Plan of Correction visit.
Rosa AyalaAdministratorFacility administrator met with LPAs during the visit.

Inspection Report

Census: 105 Capacity: 180 Deficiencies: 1 Date: 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.

Deficiencies (1)
Facility failed to ensure residents are afforded privacy; no video surveillance signage posted and not all consents required for camera usage obtained.
Report Facts
Consents for camera usage: 24

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit and authored the report
Alisa OrtizLicensing Program ManagerNamed as supervisor and licensing program manager
Rosa AyalaAdministratorFacility administrator met during the visit

Inspection Report

Census: 105 Capacity: 180 Deficiencies: 1 Date: Oct 19, 2022

Visit Reason
Licensing Program Analyst Kimberly Lyman conducted an unannounced case management visit to follow up on the facility's enrollment in the 'Safely You' program.

Findings
The facility failed to ensure residents are afforded privacy as required by California Code of Regulations, Title 22, Division 6, Chapter 8. Specifically, the facility did not have video surveillance signage posted and had not obtained all required consents for camera usage, with only 24 out of 27 consents obtained.

Deficiencies (1)
Failure to ensure residents have a reasonable level of personal privacy due to lack of video surveillance signage and incomplete camera consents.
Report Facts
Consents for camera usage: 24 Facility capacity: 180 Census: 105

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit and evaluation
Rosa AyalaAdministratorFacility administrator present during the visit
Alisa OrtizSupervisorSupervisor named in the report
Allan MacabitasMet with Licensing Program Analyst during the visit

Inspection Report

Complaint Investigation
Census: 99 Capacity: 180 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
Licensee failed to ensure resident was provided care and supervision; resident eloped and staff were unaware, posing immediate health and safety risk.
Report Facts
Capacity: 180 Census: 99 Civil penalty: 1 Plan of Correction Due Date: Jul 16, 2022

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation
Rosa AyalaExecutive DirectorFacility administrator met during investigation and named in findings
Alisa OrtizLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 99 Capacity: 180 Deficiencies: 1 Date: Jul 15, 2022

Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2022-06-22 regarding allegations including a resident eloping from the facility and concerns about staffing and care supervision.

Complaint Details
The complaint was substantiated regarding the resident eloping from the facility. Other allegations about understaffing and inadequate care were unsubstantiated due to lack of sufficient evidence.
Findings
The investigation substantiated that a resident eloped from the facility unnoticed by staff, 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.

Deficiencies (1)
Licensee failed to ensure Resident 1 was provided care and supervision, resulting in elopement and staff being unaware of the resident's absence, posing an immediate health and safety risk.
Report Facts
Capacity: 180 Census: 99 Deficiency Type: 1 Plan of Correction Due Date: Due date for plan of correction was 07/16/2022

Employees mentioned
NameTitleContext
Rosa AyalaExecutive DirectorMet with Licensing Program Analyst and involved in investigation
Kimberly LymanLicensing Program AnalystConducted the complaint investigation visit

Inspection Report

Complaint Investigation
Census: 99 Capacity: 180 Deficiencies: 1 Date: Jun 21, 2022

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

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.
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.

Deficiencies (1)
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.
Report Facts
Hours of shadowing completed by Staff 1 prior to incident: 16 Deficiency count: 1

Employees mentioned
NameTitleContext
Rosa AyalaExecutive DirectorMet with Licensing Program Analyst during the visit and discussed the incident and findings.
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit and authored the report.
Alisa OrtizLicensing Program ManagerNamed as supervisor and licensing program manager in the report.

Inspection Report

Complaint Investigation
Census: 99 Capacity: 180 Deficiencies: 1 Date: Jun 21, 2022

Visit Reason
An unannounced case management visit was conducted to follow up on an incident report received regarding medication administration errors involving two residents.

Complaint Details
The visit was triggered by a complaint incident report dated 06/07/2022 regarding medication administration errors. The complaint was substantiated by the findings.
Findings
The facility failed to ensure proper medication administration when Staff 1 administered Resident 1's medications to Resident 2, who was not prescribed those medications, while Resident 1 did not receive any medications. No adverse effects were noted, but this posed an immediate health and safety risk.

Deficiencies (1)
Failure to ensure care and supervision as evidenced by Resident 1 not receiving medication and Resident 2 receiving incorrect medications on June 7, 2022.
Report Facts
Medication dosages administered incorrectly: 4 Hours of shadowing completed by Staff 1 prior to incident: 16

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit and evaluation
Rosa AyalaExecutive DirectorMet with Licensing Program Analyst during visit and discussed findings
Alisa OrtizSupervisorNamed in report as supervisor

Inspection Report

Census: 99 Capacity: 180 Deficiencies: 0 Date: 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
NameTitleContext
Rosa AyalaExecutive DirectorMet with Licensing Program Analyst during the visit and involved in the incident investigation
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit

Inspection Report

Census: 99 Capacity: 180 Deficiencies: 0 Date: Jun 2, 2022

Visit Reason
Licensing Program Analyst Kimberly Lyman made an unannounced case management visit to follow up on an SOC 341 received by Community Care Licensing on 05/30/2022 regarding inappropriate statements made by a staff member to a resident.

Complaint Details
The visit was triggered by a complaint (SOC 341) alleging inappropriate statements by Staff 1 to Resident 1. The facility investigated, found no injuries, and reinstated the staff member after training. Staff denied abuse and challenging behaviors were noted from the resident.
Findings
No deficiencies were noted during the visit. The facility conducted an investigation, temporarily removed the staff member from schedule, and initiated an eight-step training program for Dementia care. Staff interviewed denied any abuse or inappropriate behavior.

Report Facts
Date of SOC 341: May 30, 2022 Date Staff 1 returned to work: Jun 1, 2022

Employees mentioned
NameTitleContext
Rosa AyalaExecutive DirectorMet with Licensing Program Analyst during visit
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit

Inspection Report

Complaint Investigation
Census: 97 Capacity: 180 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
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.
Report Facts
Census: 97 Total Capacity: 180 Deficiency Type A Count: 1

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the inspection and investigation
Rosa AyalaAdministratorFacility administrator met during the inspection
Alisa OrtizLicensing Program ManagerSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 97 Capacity: 180 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
Failure to provide medication assistance to Resident 1 for four days, posing an immediate health and safety risk.
Report Facts
Capacity: 180 Census: 97 Deficiencies cited: 1

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation
Alisa OrtizLicensing Program ManagerOversaw the complaint investigation
Rosa AyalaAdministratorFacility administrator present during the investigation and exit interview

Inspection Report

Complaint Investigation
Census: 97 Capacity: 180 Deficiencies: 1 Date: Apr 28, 2022

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

Complaint Details
The complaint was substantiated based on evidence including falsified medication records and staff interviews. The resident was found with bruising and a laceration after not receiving medication. The investigation met the preponderance of evidence standard.
Findings
The investigation found that the Medication Administration Record (MAR) had been falsified and the resident had not been given medication while at the facility. Staff interviews indicated medications had been sent out for re-packaging and no medications were available to administer. The allegation was substantiated, citing a failure to provide medication assistance to the resident, posing an immediate health and safety risk.

Deficiencies (1)
Failure to provide medication assistance to resident R1, who did not receive medication for four days despite being unable to manage medications, posing an immediate health and safety risk.
Report Facts
Census: 97 Total Capacity: 180 Deficiency Count: 1 Plan of Correction Due Date: Apr 29, 2022

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation and authored the report
Rosa AyalaAdministrator / Executive DirectorFacility administrator present during the investigation and exit interview
Alisa OrtizSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Complaint Investigation
Census: 97 Capacity: 180 Deficiencies: 1 Date: Apr 28, 2022

Visit Reason
An unannounced case management visit was conducted in conjunction with a complaint investigation regarding the mismanagement of Resident 1's medication.

Complaint Details
Complaint visit 22-AS-20220214103038 triggered the investigation. The complaint was substantiated based on falsification of medication records and staff interviews.
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 despite medication not being administered to the resident.

Deficiencies (1)
Conduct that is inimical to the health, morals, welfare, or safety of either an individual or the people of the State of California, posing an immediate health and safety risk to residents in care.
Report Facts
Capacity: 180 Census: 97 Plan of Correction Due Date: 1

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit and complaint investigation
Rosa AyalaAdministratorFacility administrator met with Licensing Program Analyst during the visit
Alisa OrtizSupervisorSupervisor named in relation to the inspection and deficiency

Inspection Report

Complaint Investigation
Census: 103 Capacity: 180 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
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.
Report Facts
Census: 103 Total Capacity: 180 Deficiencies cited: 1 Plan of Correction Due Date: Apr 15, 2022

Employees mentioned
NameTitleContext
Allan MacabitasDirector of Resident ServicesMet with Licensing Program Analyst during the visit and involved in the incident follow-up
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit and authored the report
Alisa OrtizLicensing Program ManagerSupervisor overseeing the inspection and cited deficiency

Inspection Report

Follow-Up
Census: 103 Capacity: 180 Deficiencies: 1 Date: Apr 14, 2022

Visit Reason
An unannounced case management visit was conducted to follow up on an incident report received on 2022-04-13 involving 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 their room despite being unable to manage medications. This posed an immediate health risk and resulted in a cited violation under California Code of Regulations.

Deficiencies (1)
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.
Report Facts
Capacity: 180 Census: 103 Plan of Correction Due Date: Apr 15, 2022

Employees mentioned
NameTitleContext
Allan MacabitasDirector of Resident ServicesMet with Licensing Program Analyst during the visit and involved in incident management
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit and authored the report
Alisa OrtizSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Annual Inspection
Census: 100 Capacity: 180 Deficiencies: 0 Date: 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
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the inspection visit
Rosalie SullivanRegional Operations SpecialistAccompanied the Licensing Program Analyst during the facility tour
Rosa AyalaAdministratorFacility administrator with current certificate

Inspection Report

Annual Inspection
Census: 100 Capacity: 180 Deficiencies: 0 Date: Feb 28, 2022

Visit Reason
Licensing Program Analyst Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required annual inspection of the facility.

Findings
The facility was found to be clean, sanitary, and well-maintained with no deficiencies noted. Residents appeared happy and well cared for, and the facility had appropriate emergency plans and COVID-19 mitigation measures in place.

Report Facts
Residents on hospice care: 5 Residents in Assisted Living: 62 Residents in Memory Care: 38

Employees mentioned
NameTitleContext
Rosa AyalaAdministratorNamed as facility administrator with current certificate
Kimberly LymanLicensing Program AnalystConducted the inspection visit
Rosalie SullivanRegional Operations SpecialistAccompanied the Licensing Program Analyst during the facility tour

Inspection Report

Complaint Investigation
Census: 76 Capacity: 180 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
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.
Report Facts
Capacity: 180 Census: 76 Plan of Correction Due Date: Jun 8, 2021 Medications given in error: 7

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation
Alisa OrtizLicensing Program ManagerOversaw the complaint investigation
Nerissa LagmayAdministratorFacility administrator named in the report
Rosa AyalaExecutive DirectorMet with Licensing Program Analyst during investigation and exit interview
Colleen PappsExecutive DirectorMet with Licensing Program Analyst during investigation
Staff 1Licensed Vocational Nurse (LVN)Staff member who dispensed incorrect medication

Inspection Report

Complaint Investigation
Census: 76 Capacity: 180 Deficiencies: 1 Date: Jun 7, 2021

Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that staff dispensed incorrect medication to a resident.

Complaint Details
The complaint was substantiated. Staff dispensed incorrect medication to a resident, who was hospitalized for observation but returned the same day without adverse effects.
Findings
The investigation substantiated that on 05/26/2021, a staff member dispensed the incorrect medication to a resident, resulting in the resident being hospitalized for observation. The facility provided re-training to the staff involved.

Deficiencies (1)
Failure to ensure care and supervision was provided to Resident 1, who was inadvertently given seven medications belonging to another resident, posing an immediate health and safety risk.
Report Facts
Census: 76 Total Capacity: 180 Deficiency Type A: 1

Employees mentioned
NameTitleContext
Kimberly LymanLicensing Program AnalystConducted the complaint investigation
Nerissa LagmayAdministratorFacility administrator named in the report
Colleen PappsExecutive DirectorMet with Licensing Program Analyst during investigation
Rosa AyalaExecutive DirectorMet with Licensing Program Analyst during investigation and exit interview

Inspection Report

Complaint Investigation
Census: 67 Capacity: 180 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
Failed to ensure S1's criminal clearance was transferred to the facility, posing an immediate health and safety risk to residents.
Report Facts
Census: 67 Total Capacity: 180 Deficiencies cited: 1

Employees mentioned
NameTitleContext
Logan CooleyExecutive DirectorReported the allegation to authorities and facility representatives during the visit
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit and inspection
Alisa OrtizLicensing Program ManagerSupervisor overseeing the inspection
Nerissa LagmayDirector of Resident ServicesMet with Licensing Program Analyst during the visit
Colleen PappExecutive DirectorArrived during the visit and participated in discussions

Inspection Report

Complaint Investigation
Census: 67 Capacity: 180 Deficiencies: 1 Date: Apr 13, 2021

Visit Reason
An unannounced case management visit was conducted to follow up on an incident report received on 04/13/2021 regarding an allegation of inappropriate conduct by a staff member towards a resident.

Complaint Details
The visit was complaint-related following an incident report alleging inappropriate conduct by a staff member. Deputies interviewed the resident but did not open a case as no crime was committed. Further investigation was required.
Findings
The investigation found that the staff member in question 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 the staff member, posing an immediate health and safety risk.

Deficiencies (1)
Failure to ensure Staff 1's criminal clearance was transferred to the facility, posing an immediate health and safety risk to residents.
Report Facts
Capacity: 180 Census: 67 Deficiencies cited: 1 Plan of Correction Due Date: Apr 14, 2021

Employees mentioned
NameTitleContext
Logan CooleyExecutive DirectorReported the incident to authorities and facility representative during the visit
Kimberly LymanLicensing Program AnalystConducted the unannounced case management visit and inspection
Nerissa LagmayDirector of Resident ServicesMet with Licensing Program Analyst during the visit
Colleen PappExecutive DirectorArrived during the visit and met with Licensing Program Analyst

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