331881395-4-19-2023-18-AS-CNWE-CR2SVJ-20230419141249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881395
Report Date: 04/19/2023
Date Signed: 04/19/2023 02:13:45 PM

Document Has Been Signed on 04/19/2023 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BELLA CASA 3		FACILITY NUMBER:	331881395
ADMINISTRATOR:	CARLOS, ROMMEL; URSULA		FACILITY TYPE:	740
ADDRESS:	77583 CARINDA COURT		TELEPHONE:	(760) 772-5089
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92211
CAPACITY: 6		CENSUS: 0	DATE:	04/19/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Rommel Carlos and Ursula Carlos		TIME COMPLETED:	02:30 PM

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On 4/19/2023, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an announced pre-licensing inspection at the facility. LPA Nwogene met with Applicants, Rommel Carlos and Ursula Carlos and toured the inside and outside of facility.

Application: The application is for a change of location for a Residential Care Facility for the Elderly. The fire clearance has been granted for six (6) non-ambulatory residents, of which one (1) may be bedridden.

Buildings and Grounds: The home is composed with living room, kitchen, dining room, Tv room , five (5) clients bedrooms, 3 restrooms, a staff room, laundry room, backyard, and a garage. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Rommel and Ursula, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are furnished and privacy is available. The dining and living room areas/furniture are clutter free and in good condition. Bathrooms were observed to have non-slip mats available. The hot water was tested and measured at 118 degrees Fahrenheit which is within regulatory limits. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order. Central heating and air conditioning system installed with central panels located in the living room and bedroom #5 to control entire house.

Storage and Supplies: Medications will be stored in a locked cabinet in the hallway, inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in the laundry room, inaccessible to clients. A Fire extinguisher was available and fully charged.

CONTINUE ON LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA CASA 3	FACILITY NUMBER: 331881395
	VISIT DATE: 04/19/2023

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CONTINUED FROM LIC809

Activities: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition with a covered patio to provide shade over the outside table and chairs. Activity supplies are present inside the home, including television, magazines, and games.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked kitchen drawer, available only to authorized individuals. Trash cans has tight-fitting lid. Dishwasher will be used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 40 degrees Fahrenheit and Freezer was measures at 0 degrees Fahrenheit.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Personal Rights, a Facility Sketch (LIC 999), and Complaint Information.

Missing Items:
Due to this is a change of location, some items listed below was not present at the home. Rommel and Ursula stated the items are in the old facility and are currently being used by the residents but a proof in form of a picture of the items listed below will be provided to LPA within 10-days of when the residents move in.

Window Screens
Facility phone
Night Lights
Flashlights
Rights of Resident Councils Poster
Bedroom #4 bed, mattress, chair, nightstand, dresser, and Lamp.

A proof of installed window screens must be provided to LPA before applicant is recommended for licensure. Once LPA Nwogene receives the proof of the installed window screens, LPA will inform the Centralized Applications Bureau (CAB) that the home is ready for licensure. Applicant will be notified of the license approval.

Component III was completed during today's visit and a copy was given to Rommel Carlos and Ursula Carlos for future reference.

An exit interview was conducted were this report was discussed with and provided to Rommel Carlos and Ursula Carlos.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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