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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880721
Report Date: 10/16/2024
Date Signed: 10/16/2024 04:42:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/09/2024 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20241009202048
FACILITY NAME:BELLA CORTINA RESIDENTIAL CARE FACILITYFACILITY NUMBER:
331880721
ADMINISTRATOR:KHAN, SANAFACILITY TYPE:
740
ADDRESS:28571 YAROW WAYTELEPHONE:
(951) 208-4125
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 6DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Musarrat Khan, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Musarrat Khan, and informed her of the purpose for the visit.

A report was received by the Department alleging Resident One (R1) received the incorrect medications, which belonged to another resident in care, resulting in a hospitalization. The investigation included staff and resident interviews, review and collection of relevant documentation, and a tour of the interior and exterior areas of the home. R1 was interviewed and confirmed they were given the incorrect medication on one (1) occasion. R1 reported Staff One (S1) prepared the medications and Staff Two (S2) issued the medications to them on a meal tray. R1 reported they did ingest the medications that were provided. R1 reported staff noticed the medications were incorrectly given about five minutes later. R1 reported they were sent to the hospital as a result of taking the incorrect medications; however, they denied any negative symptoms attributed to the medications. S1 was interviewed and confirmed R1 was issued the wrong medications on 10/09/2024, at
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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 3
Control Number 18-AS-20241009202048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BELLA CORTINA RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 331880721
VISIT DATE: 10/16/2024
NARRATIVE
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 around 10:00 AM. S1 reported they prepared the medications in cups, left the medications on a meal tray on the kitchen counter, stepped away to use the restroom, and when they returned, noticed one tray was gone about five (5) to ten (10) minutes later. S1 reported they observed R1 had the missing tray and immediately noticed the medications were incorrectly given. S1 reported as a result of the medication error, Manager, Faiz Khan, and R1's nurse practitioner were contacted. S1 reported the nurse practitioner recommended R1 be sent to the emergency room due to the amount of medications the resident took, which was about ten (10) pills. S2 was interviewed and confirmed R1 was incorrectly given the wrong medications after they (S2) issued the wrong meal tray to the resident. S2 reported they could not read the name on the tray, though believed it was R1's tray based on the arrangement the tray was in. S2 reported they did not observe R1 to have any symptoms after taking the incorrect medications. S2 reported the manager, Faize, and the nurse practitioner were contacted. S2 reported emergency services was contacted after R1's blood pressure had been monitored and once the resident agreed to be sent out to the hospital.

R1's Admission agreement revealed the resident was to receive assistance with medication administration. An After Visit Summary that was on file at the facility revealed R1 was hospitalized on 10/09/2024 for both Dizziness and Drug Overdose. No diagnosis was listed on the report. Medical records were subpoenaed on 10/14/2024; however, they were not obtained prior to the closure of the investigation. An Unusual Incident/Injury Report (UIR) was obtained from the facility on 10/10/2024. The report revealed the date of the incident was 10/09/2024. The report revealed staff accidentally took another resident's medication cup with the tray to R1. The report revealed manager, Faiz, the Administrator, Musarrat Khan, and R1's nurse practitioner were notified of the incident. The report revealed R1's vitals were immediately checked, and the resident was observed to be stable and their normal self. The report revealed R1 was later transported to the hospital for observation.

Therefore, based on interviews and records, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. This violation posed a potential threat to the health, safety, and personal rights of the resident in care. A citation will be issued.

An exit interview was conducted; this report was reviewed with Administrator, Musarrat Khan, and a copy, along with the LIC 811, LIC 9098, and instructions on appeal rights were provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20241009202048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA CORTINA RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 331880721
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2024
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care: (a) A plan for incidental medical & dental care shall be developed by each facility. The plan shall encourage routine medical & dental care & provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with
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Proof of training on new medication procedures and on the six rights of safe medication administration was observed on file. POC is cleared.
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self-administered medications as needed. This requirement was not met, as evidenced by: Based on interviews and records, R1 was administered the wrong medications on 10/09/2024 resulting in a hospitalization.
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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: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
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