306005563-5-26-2026-22-AS-AORZ-DV63J6-20260617181702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005563
Report Date: 05/26/2026
Date Signed: 05/26/2026 03:01:02 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2026 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20260107132248

FACILITY NAME:	BELMONT VILLAGE ALISO VIEJO		FACILITY NUMBER:	306005563
ADMINISTRATOR:	AYALA, ROSA		FACILITY TYPE:	740
ADDRESS:	300 FREEDOM LN		TELEPHONE:	(949) 643-1050
CITY:	ALISO VIEJO	STATE: CA	ZIP CODE:	92656
CAPACITY:	180	CENSUS: 131	DATE:	05/26/2026
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Morgan Sommer		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff excluded resident's authorized person from making decisions regarding resident's care
Staff retained resident at the facility without consent or court order

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as court documents. Regarding the allegations that Staff retained resident at the facility without consent or court order and Staff excluded resident's authorized person from making decisions regarding resident's care, the investigation revealed the following:
R1 has Durable Power of Attorney (DPOA) paperwork dated July 6, 2021, designating three family members as agents of healthcare and financial decisions. The Department reviewed a Probate Settlement Agreement dated 06/10/2025 through the Superior Court of Orange County. Agreement indicates if R1 is unable to be safely maintained in the home, the resident will be moved to a memory care unit. The document indicates Resident 1 (R1) had been refusing caregivers in the home. Guardian ad Litem report dated 01/23/2026 indicated that the resident was unable to return home. CONTINUED ON LIC 9099 C DATED 05/26/2026

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 22-AS-20260107132248

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BELMONT VILLAGE ALISO VIEJO	FACILITY NUMBER: 306005563
	VISIT DATE: 05/26/2026

NARRATIVE

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The agreement was signed by all three agents, as a result R1 was moved into facility for care. Per communications provided by the facility, all three DPOAs are kept informed of R1’s ongoing care. Based on interviews conducted and record review, the allegations are deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2026 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20260107132248

FACILITY NAME:	BELMONT VILLAGE ALISO VIEJO		FACILITY NUMBER:	306005563
ADMINISTRATOR:	AYALA, ROSA		FACILITY TYPE:	740
ADDRESS:	300 FREEDOM LN		TELEPHONE:	(949) 643-1050
CITY:	ALISO VIEJO	STATE: CA	ZIP CODE:	92656
CAPACITY:	180	CENSUS: 131	DATE:	05/26/2026
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Morgan Sommer		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff caused injury to resident in care
Unauthorized staff are providing care and supervision to resident
Staff interfered with resident's ability to make phone calls
Staff providing resident medication under false pretense
Staff did not follow reporting requirements
Staff yelled at resident
Staff made inappropriate comments towards resident
Staff do not ensure resident is adequately fed
Staff do not take precautions to mitigate the spread of illness in the facility
Staff did not seek medical treatment for resident in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as facility progress notes. Regarding the allegation that staff do not ensure resident is adequately fed: Three out of three staff, two out of three witnesses and two out of two companions state R1 will eat meals but refuses food at times. Staff indicate getting different food items as requested by the resident. Memory Care Director indicates resident was admitted to hospice due to weight loss from refusing to eat. R1’s Designated Power of Attorney’s (DPOAs) were kept informed of R1’s refusals to eat. Per LPA’s review of facility dietician report dated 04/13/2026, facility meals appear to meet nutrition and quality requirements. LPA toured the facility kitchen and observed facility had ample supply to meet two day perishable and seven day non-perishable food requirements as well as menus with ample choices. CONTINUED ON LIC 9099C DATED 05/26/2026

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20260107132248

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BELMONT VILLAGE ALISO VIEJO	FACILITY NUMBER: 306005563
	VISIT DATE: 05/26/2026

NARRATIVE

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Regarding the allegation that staff do not take precautions to mitigate the spread of illness in the facility: Private Care Companion 1 (CC) denies working at the facility with Covid or any other illness. LPA observed the facility to be clean and sanitary with infection prevention practices. Administrator denies being aware of any staff or companion working with Covid. LPA attempted to interview Resident 1 (R1) who refused to speak with LPA. During the facility annual conducted on February 19, 2026, LPA reviewed six staff files and confirmed facility staff have required training's on infection control. CC was hired privately by R1’s family and was therefore not subject to facility staff required training's. LPA toured the facility and observed the facility had ample Personal Protective Equipment (PPE) to meet residents needs in care.

Regarding the allegation that staff did not seek medical treatment for resident in a timely manner, staff caused injury to resident in care, staff made inappropriate comments towards resident and staff yelled at resident: Review of facility progress notes show that medical attention was obtained for the resident on three different occasions between 09/02/2025-01/03/2026 for urinary tract infections, 09/25/2025 for redness on the lips, 09/20/2025 for antibiotic eye drops, 09/13/202 for low blood pressure, 07/17/2025 for swelling of the leg and ankle, and three occasions between 09/14/2025-10/16/2025 for falls without injury. Facility documentation indicates responsible party was notified. Three out of three staff, two out of two care companions and two out of three witnesses deny being aware of any allergic reactions or unreported injuries. Witness provided photos of bruising on the resident’s legs however LPA is unable to determine the incident and two out of two staff, two out of three witnesses and two out of two care companions deny the injury as well as witnessing any yelling, physical abuse or inappropriate language directed at resident. Resident 1 refused to speak with LPA regarding the allegations. During the facility annual conducted on February 19, 2026, LPA reviewed six staff files and confirmed facility staff have required personal rights training.

Regarding the allegation staff interfered with resident's ability to make phone calls: LPA observed resident’s phone during visit to facility. Resident was sitting on phone and stated that it is where the resident likes to keep the phone. Resident confirmed preferring a cell phone as the resident can always keep it with her. LPA attempted to further interview resident however resident declined to continue to speak with LPA. Resident, staff, witnesses and care companions all confirm resident uses the phone when they wish and chooses who to talk to.
CONTINUED ON LIC 9099C DATED 05/26/2026

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260107132248

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BELMONT VILLAGE ALISO VIEJO	FACILITY NUMBER: 306005563
	VISIT DATE: 05/26/2026

NARRATIVE

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Regarding the allegation unauthorized staff are providing care and supervision to resident: Per resident appraisal dated 01/13/2026, R1 is receiving assistance with activities of daily living including showering, dressing, grooming, toileting and escorting. Two out of two staff, two out of three witnesses and two out of two care companions confirm facility staff is providing the caregiving when the resident allows. Resident appraisal notes R1 is prone to refusing care. Care companions state accompanying resident for toileting but not providing actual toileting care. LPA observed the care companions are criminally cleared and associated to the facility.
Regarding the allegation staff providing resident medication under false pretense: Facility caregivers indicate med techs provide all the medications. Two out of two care companions deny having anything to do with the resident’s medications and deny speaking to the resident about the medications. Two out of three witnesses and two out of two care companions deny any knowledge of care companions calling medications “Vitamins” and stated satisfaction with facility’s administration of medications. Family interactions regarding medications are outside the department’s prevue. Seroquel was ordered by the physician, and facility is required to follow the physician's orders.
Regarding the allegation Staff did not follow reporting requirements: LPA observed incident reports submitted to the department regarding the resident including send outs to the hospital. Administrator and staff deny knowledge of any unreported injuries or allergic reactions. LPA did not observe any documentation regarding any unreported incidents in the progress notes. Three out of three witnesses stated W1 was the point person however, LPA reviewed documentation including emails showing all three DPOA’s were informed regarding R1’s care.
Due to cognitive decline, LPA unable to interview residents in the memory care unit.

Based on records reviewed and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report was provided to facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC9099 (FAS) - (06/04)

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