<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530124
Report Date: 07/18/2025
Date Signed: 07/18/2025 12:07:22 PM

Document Has Been Signed on 07/18/2025 12:07 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BELLA CAI CARE HOMEFACILITY NUMBER:
335530124
ADMINISTRATOR/
DIRECTOR:		ABDULLAH, SITI KHATIJAHFACILITY TYPE:
740
ADDRESS:29111 OAK GROVE WAYTELEPHONE:
(562) 537-8885
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 6CENSUS: 4DATE:
07/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator/Licensee- Charise MagsaysayTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Rico conducted an unannounced case management visit pertaining to residents’ eviction. LPA Rico met with staff Cresenaio Galve and explained the purpose of the visit. The Administrator Charise Magsaysay was contacted and informed about today’s visit. During today’s visit, LPA Rico conducted staff interviews, reviewed facility’s documents, and toured the facility.

Upon record review, it was revealed that R1 was not provided with a 30-day eviction notice. The Administrator Charise informed LPA that R1 had requested to move out. The Administrator indicated that they had assisted with finding a new facility for R1. In addition, R1 did not provide a 30-day notice of move-out date to the facility. Per resident interview, R1 stated they did not want to move out. During facility tour, LPA observed R1 personal belongings were still located inside the facility. LPA informed the Administrator that the facility must follow Community Care Licensing Eviction Procedures.

Furthermore, LPA Rico reviewed R1 physician report which indicated R1 is unable to manage own cash resources. The facility did not have residents' cash resources maintained as a drawing account which would include ledger accounting (columns for income, disbursements and balance) for each resident, and supporting receipts filed in chronological order. A deficiency will be issued. In addition, it was revealed the facility did not have a surety bond. A deficiency will be issued. Based on the information gathered today’s visit three (3) deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809D) was discussed and provided to Administrator Charise Magsaysay. Along with a copy of appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
Document Has Been Signed on 07/18/2025 12:07 PM - It Cannot Be Edited


Created By: Mary Rico On 07/18/2025 at 09:30 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 CAI CARE HOME
FACILITY NUMBER: 335530124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2025
Section Cited
CCR
87468(a)(20)

1
2
3
4
5
6
7
To be protected from involuntary transfers, discharges, and evictions.. state.. and relocation protections for residents. For purposes of this paragraph.. means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident
1
2
3
4
5
6
7
The Administrator stated they will read the regulation cited 87468.2(A)(20) and will send a self-verification letter they have read and understood the regulation.
8
9
10
11
12
13
14
This requirement wasn't met as evidenced by: Based on interviews,and facility tour, the Administrator did not follow the proper relocaton the facility which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
POC due date by 7/21/2025
Type A
07/21/2025
Section Cited
CCR87216(a)

1
2
3
4
5
6
7
87216(a) Bonding Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.
1
2
3
4
5
6
7
The Administrator stated they will read the regulation cited 87216(a) and will send a self-verification letter they have read and understood the regulation.
8
9
10
11
12
13
14
This requirement wasn't met as evidenced by: Based on record review the Licensee did not have a surety bond which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
POC due date 7/21/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/18/2025 12:07 PM - It Cannot Be Edited


Created By: Mary Rico On 07/18/2025 at 11:26 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 CAI CARE HOME
FACILITY NUMBER: 335530124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2025
Section Cited
CCR
87217(g)(1)

1
2
3
4
5
6
7
87217(g)(1)Safeguards for Resident Cash, Personal Property, and Valuables Records of residents' cash resources maintained as a drawing account shall include a ledger accounting... for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current.
1
2
3
4
5
6
7
The Administrator stated they will read the regulation cited 87217(g)(1) and will send a self-verification letter they have read and understood the regulation.
8
9
10
11
12
13
14
This requirement wasn't met as evidenced by: Based on record review the Licensee did not have a copy of R1 ledger account which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
POC due date by 7/21/2025

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4