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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881395
Report Date: 05/24/2024
Date Signed: 05/24/2024 03:57:33 PM

Document Has Been Signed on 05/24/2024 03:57 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BELLA CASA 3FACILITY NUMBER:
331881395
ADMINISTRATOR/
DIRECTOR:		CARLOS, ROMMEL; URSULAFACILITY TYPE:
740
ADDRESS:77583 CARINDA COURTTELEPHONE:
(760) 772-5089
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY: 6CENSUS: 6DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Rommel Carlos, Licensee TIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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On today's date 05/24/24 LPA conducted an unannounced 1 year required visit. LPA was greeted and entry by Caregiver Flordeiza Bonilla. The Administrator Ursula Carlos-and Licensee Rommel Carlos arrived shortly after. The facility is licensed to serve age range 60 and over, 6 non-ambulatory, of which 1 may be bedridden. Bedroom #5 (Master) is the designated room for a bedridden resident. The facility also has an approved hospice waiver for 6. There is currently one (1) resident that is receiving hospice services. Below are the observations made during today's inspection:

LPA conducted a tour of the interior and exterior of the facility, the facility was observed to be clean, clutter and odor free. The facility is a single story home with 6 bedrooms, 1 of which is for caregiver's, office, 3 bathrooms, laundry room, garage, backyard and kitchen. There is a shaded patio with plenty of space for seating and to promote socialization.

All staff present at the facility were observed to have obtained criminal record clearance and were associated to the facility. The emergency disaster drills are being conducted on a quarterly basis and the last drill was conducted on 4/30/24. The smoke and carbon monoxide detectors were tested and were found to be operable. The hot water was tested and found to be within regulatory limits measuring between 109.2-116.2 degrees F. The facility has a mitigation plan on file that was submitted on 3/21/21. There are no known guns or ammunition on the premises, nor are there any pools or bodies of water.

The medications are locked inside a cabinet directly outside of bedroom #5. The medications were reviewed and are given according to the physician's instructions. The knives and other sharp objects are stored inside a locked drawer underneath the stove. The chemicals and other hazardous items are locked underneath the kitchen sink and inside a cabinet in the locked laundry room.

The facility food supply met the requirement as there was a 2 day supply of perishable and a 7 day supply of
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BELLA CASA 3
FACILITY NUMBER: 331881395
VISIT DATE: 05/24/2024
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non perishable food items observed. There is a refrigerator, and deep freezer in the garage as wel.l that was observed to be fully stocked.

LPA conducted a review of all resident files all required documentation was present such as a medical assessment, admission's agreement and appraisal were observed. LPA conducted a review of 3 staff files and observed for the required documentation to be present such as application, and criminal record clearance. However the three of three staff files reviewed revealed that the Cardiopulmonary Resuscitation (CPR) expired on 10/28/23. LPA was informed that the class was taken but there was no proof available for LPA to review during the time of the visit, therefore a citation is being issued.

LPA discussed conducting a review of facility personnel roster to ensure all staff are associated to the facility. In addition conducting a review of personnel files to ensure that all necessary documentation is present as well as current such as Identification .

Based on today's inspection a citation will be issued on the attached 809D in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).



An exit interview was conducted and a copy of this report, appeal rights and LIC 9098-Proof of Corrections form was reviewed and provided to Rommel Carlos, Licensee.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2024 03:57 PM - It Cannot Be Edited


Created By: Javina George On 05/24/2024 at 03:35 PM
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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review the licensee did not comply with the section cited above in 3 out of 3 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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The Licensee agreed to conduct an audit and enroll staff in CPR class or submit proof to verify that staff have obtained valid CPR certification. Proof of correction is to be submitted to the department by 5pm on the due date indicated (5/25/24).
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
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