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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881395
Report Date: 06/08/2023
Date Signed: 06/08/2023 12:34:38 PM

Document Has Been Signed on 06/08/2023 12:34 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 3FACILITY NUMBER:
331881395
ADMINISTRATOR:CARLOS, ROMMEL; URSULAFACILITY TYPE:
740
ADDRESS:77583 CARINDA COURTTELEPHONE:
(760) 772-5089
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY: 6CENSUS: 6DATE:
06/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee's Rommel and Ursula CarlosTIME COMPLETED:
10:38 AM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George conducted an unannounced case management deficiencies visit. LPA was at the facility to investigate and deliver findings for a complaint. LPA met with Licensee's Rommel and Ursula Carlos.

LPA conducted a tour of the interior and exterior of the facility and observed the following:

-Resident #1(R1) was observed to have an audio/visual surveillance device inside their bedroom. The facility staff did not obtain consent to utilize an audio/visual surveillance device, therefore a deficiency will be cited according to the California Code of Regulations.

There were no other health or safety concerns observed during LPAs visit.

An exit interview was conducted, and a copy of this report, and appeal rights were provided to Licensee's Rommel and Ursula Carlos.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/08/2023 12:34 PM - It Cannot Be Edited


Created By: Javina George On 06/08/2023 at 11:37 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BELLA CASA 3
FACILITY NUMBER: 331881395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2023
Section Cited
CCR
87468.2(a)(1)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition.. residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy..

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The licensee agrees to remove the device and speak with responsible party in regards to obtaining a smart caregiver mat. Proof is to be submitted to the department by 5pm on the due date indicated.
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This requirement is not met as evidenced by: Based on observation, LPA observed an audio recording monitoring in R1's bedroom, The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023


LIC809 (FAS) - (06/04)
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