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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206952
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:08:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2021 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20211101082313
FACILITY NAME:BELLA CARE HOME LLCFACILITY NUMBER:
107206952
ADMINISTRATOR:GONZALES, MARILENFACILITY TYPE:
740
ADDRESS:508 GATEWAY AVETELEPHONE:
(559) 259-6228
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:6CENSUS: 6DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Administrator, Marilen GonzalesTIME COMPLETED:
01:23 PM
ALLEGATION(S):
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Staff is not properly trained
Staff left resident in a wheelchair that was positioned in an unsafe manner
INVESTIGATION FINDINGS:
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On 8/10/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced complaint visit to deliver findings. LPA was COVID pre-screened at time of entry. Administrator was contacted and reason for visit was discussed. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms.

During investigation, LPA completed interviews with RP, staff and residents. LPA reviewed 4 of 4 staff files located at the facility. 4 of 4 files were not complete. LPA observed photo of R3 in an unsafe position in their wheelchair. Wheelchair was observed to be leaning on a chair with the front wheels of the wheelchair in the air. The allegations listed above are found to be SUBSTANTIATED based on LPA’s record reviews and observations. Per Title 22, deficiencies cited on LIC9099-D.

Exit interview completed. Appeal rights and a copy of this report given.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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 2
Control Number 24-AS-20211101082313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BELLA CARE HOME LLC
FACILITY NUMBER: 107206952
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2022
Section Cited
CCR
87707(a)(2)
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87707 Training Requirements If Advertising Dementia Special Care, Programming And/Or Environments (2) Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period...
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Licensee stated training will be completed and record documentation will be updated and maintained accordingly. Licensee to provide updated records by POC date.
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This requirement was not met as evidence by: LPA's observation of 4 of 4 personnel files having incomplete training records. This posess a potential health and safety or personal rights risk to residents in care.
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Type B
08/19/2022
Section Cited
CCR
87411(d)(3)
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87411 Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them...as evidenced by safe and effective job performance:(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
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Licensee to provide training to all staff on regulations. A sign in sheet and training material to be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA's observation of a picture provided during investigation. The picture showing R3 in a wheelchair leaning back with the wheels of the wheelchair in the air. This poses a potential health and safety or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2