331881395-6-8-2023-18-AS-JESL-CT2VJJ-20230622162850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881395
Report Date: 06/08/2023
Date Signed: 06/08/2023 12:34:08 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, 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
05/31/2023 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230531150052

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: 6	DATE:	06/08/2023
		UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Ursula Carlos, Licensee		TIME COMPLETED:	10:38 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of care and supervision.
Facility is not following residents health care directive.
Resident is not being afforded privacy with phone calls and visits.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licesning Program Analyst(LPA) made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation(s) listed above. LPA was greeted and granted entry by the Licensee Ursula Carlos, where explained the purpose of the visit and the elements of the allegation(s). Mrs. Carlos stated that the facility does not have Resident #1 (R1) residing at the facility, as they are at the sister facility.

In addition, LPA was provided a copy of the resident roster, and did not see R1 on the list. Based on observation, interviews and record review all three (3) allegations Lack of care and supervision, facility is not following residents health care directive, and resident is not being afforded privacy with phone calls and visits are UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the department had there dismissed the complaint.

An exit interview was conducted and a copy of this report was provided to Rommel and Ursula Carlos.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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

LIC9099 (FAS) - (06/04)

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