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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426776
Report Date: 06/08/2023
Date Signed: 06/08/2023 12:55:18 PM

Substantiated


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
06/08/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230608093111
FACILITY NAME:BELLA CASA 2FACILITY NUMBER:
336426776
ADMINISTRATOR:CARLOS, ROMMELFACILITY TYPE:
740
ADDRESS:77-632 BARONS CIRTELEPHONE:
(760) 772-5089
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY:6CENSUS: 5DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Licensee's Rommel and Ursula CarlosTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident is not being afforded privacy with phone calls and visits.
INVESTIGATION FINDINGS:
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Licesning Program Analyst(LPA) made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation 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. The allegation was investigated, the investigation consisted of observation, interviews and record review.

LPA conducted a tour of the interior and exterior and observed for there to be a video surveillance device in three (3) of the five (5) resident bedrooms. Per the Licensee Resident #1 (R1)s significant other installed the camera in their room, and is the one that monitors the device. However R1 has a roommate and there was no proof of consent, but the Licensee stated that verbal approval was provided agreeing to have a camera and or audio device inside their bedroom. R3 and R4 were observed to have a device inside their room as well, and their responsible parties are reported to have given writtenconsent, however the written approval was not at the facility at the time of LPA's visit. The facility did not obtain approval to utilize any form of video sureveillance from the department.
Substantiated
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)
Page: 1 of 4
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
06/08/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230608093111

FACILITY NAME:BELLA CASA 2FACILITY NUMBER:
336426776
ADMINISTRATOR:CARLOS, ROMMELFACILITY TYPE:
740
ADDRESS:77-632 BARONS CIRTELEPHONE:
(760) 772-5089
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY:6CENSUS: 5DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Licensee's Rommel and Ursula CarlosTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Lack of care and supervision.
Facility is not following residents health care directive.
INVESTIGATION FINDINGS:
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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). The allegations were investigated the investigation consisted os observation, interviews and record review.

Regarding the allegation lack of care and supervision. Resident #1 (R1) is diagnosed with having high blood pressure and is prescribed medication that is to be taken two times a day. In addition per the Licensee Mrs. Ursula Carlos, the facility takes/checks all residents vitals daily, as this is used to track and determine each resident's baseline, however it is not used to make any decisions. It was reported that R1 had asked what their blood pressure was and staff had not been provided it to R1. Staff had no knoweledge of the alleged incident. Mrs. Carlos did confirm that R1 did have elevated blood pressure for almost 10 days. However R1 is receiving home health services and instructed the facility to check R1's blood pressure three times a day.
Unsubstantiated
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)
Page: 4 of 4
Control Number 18-AS-20230608093111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2
FACILITY NUMBER: 336426776
VISIT DATE: 06/08/2023
NARRATIVE
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LPA attempted to interview R1 in regards to the matter but was not able to confirm or deny if they were not provided a response in regards to what their blood pressure reading was for the day. R1 stated that they were confused and became emotional. Based on LPA not being able to confirm what was alleged the allegation is UNSUBSTANTIATED.

Regarding the allegation Facility is not following residents health care directive.
It was alleged that R1's blood pressure has been elevated for approximately one week and the facility has dismissed R1's requests to be transported to the emergency room. On or around May 29, 2023, R1 had verbally requested to be transported to the hospital via paramedics and R1's Power of Attorney (POA) cancelled the paramedics resulting in R1 not receiving any medical attention. LPA was unable to confirm with R1 if they did in fact request to be sent out via 9-1-1. However the paramedics, as well as the Thermal Sheriff deputies responded to the facility. After an assessment was completed by the EMTs, it was determined that R1 did not need to be sent out for a medical evaluation. Therefore the allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was 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
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20230608093111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2
FACILITY NUMBER: 336426776
VISIT DATE: 06/08/2023
NARRATIVE
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Based on observation the allegation is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.

An exit interview was conducted and a copy of this report, 9099D 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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20230608093111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2
FACILITY NUMBER: 336426776
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
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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 will encourage the the responsible to utilize usingoom. 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 video cameras in R1, R2, R3 and R4's bedooms. 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4