BELMONT GUESTS RETREAT I

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

87211 (a)(1)(A) Reporting Requirements (a)Each licensee shall furnish... A written report... submitted to the licensing agency ... within seven days of... Death of any resident from any cause regardless of where the death occurred, This requirement is not met as evidenced by: Based on record review, interview, and observation, the licensee did not comply with the section cited above. A Death Report was not submitted to CCLD Orange County Regional Office within 7 days of when R1 passed away. This poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee states they will send a copy of the LIC624A Death Report to CCLD via email to edward.kim@dss.ca.gov by POC due date November 10, 2025.

Deadline recorded: Nov 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(5)(A)

Regulation authority

CCR

What the official deficiency says

87507(g)(5)(A) Refund conditions. (A)Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. This requirement is not met evidenced by: Based on record review, interview, and observation, the licensee did not comply with the section cited above. A refund was not issued to R1’s responsible party who paid for the month of October. This poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee states they will pay a refund of $3725.80 to R1’s Responsible Party who paid the October payment and will send proof of payment to CCLD via email to Edward.kim@dss.ca.gov by POC due date November 10, 2025.

Deadline recorded: Nov 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in three out of four resident files which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/15/2022 Plan of Correction Facility needs to update forms and email LPA Claudia Gutierrez copies of the forms completed by 04/15/2022.