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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604790
Report Date: 08/01/2024
Date Signed: 09/19/2024 01:08:31 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2024 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20240731112008
FACILITY NAME:BELLAHOMECARE IFACILITY NUMBER:
374604790
ADMINISTRATOR:COOK, CHERRYFACILITY TYPE:
740
ADDRESS:629 GUAVA AVETELEPHONE:
(406) 998-8022
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:6CENSUS: DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Caregiver Lide Cerna and Administrator Cherry CookTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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-Licensee involuntary transferred/discharged a resident.
-Licensee did not serve resident the required eviction notice.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Lide Cerna. LPA also spoke with Adminisrator Cherry Cook via phone.

The Complainant alleged that Licensee involuntarily transferred/discharged Resident #1 (R1) from the facility. They also alleged that Licensee did not serve R1 or their responsible person (RP) with the required eviction notice. CCLD’s investigation involved an unannounced facility tour, review of pertinent care and administrive records, and interviews of pertinent facility staff and outside sources.


[CONTINUED ON LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 3
Control Number 08-AS-20240731112008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELLAHOMECARE I
FACILITY NUMBER: 374604790
VISIT DATE: 08/01/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

Interviews and records aligned to show: At the time R1 moved into the facility on 02-01-2023, RP signed R1’s Admissions Agreement with the facility, as their responsible person. R1’s doctor had diagnosed R1 with Dementia, determined they were confused/disoriented, and wrote that R1 was both bedridden and paralyzed on the left side of their body due to a prior cerebral infarction. In the few months leading up to the date of their move out, R1’s incurred a partial rent balance with the facility that was past due, and attempts to resolve the balance hit a dead end. Licensee leveraged R1’s hospice agency to find alternate housing for R1 and to arrange R1’s transport there. On 06-04-2024, without RP’s consent (and R1 was not capable of consenting), R1 was physically moved out of Bellahomecare I to another care facility. While Licensee may have had a valid reason to evict on the basis of “nonpayment of the rate for basic services within ten days of the due date,” they did not serve R1 or their RP with the required 30-day written eviction notice.

Based on records and interviews, a preponderance of evidence exists to show that Licensee involuntary transferred/discharged R1 from the facility and that Licnesee did not serve R1 or their RP with the required 30-day eviction notice described in regulation. Both allegations are therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Cook via phone. A copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240731112008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELLAHOMECARE I
FACILITY NUMBER: 374604790
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2024
Section Cited
CCR
87468.2(a)(20)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions.”
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Per interview of R1’s RP, they do not desire/intend for R1 to return to the facility; this resolves the immediate risk. Licensee also agreed to retrain all current facility staff and managers on Resident’s Personal Rights (as articulated in CCLD’s form LIC613C-2). Licensee agreed to E-mail the training sign-in sheet to to LPA by 09-01-2024.
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This requirement was not met, as evidencd by: Based on records review and interviews, Licensee did not ensure that 1 of 6 residents (R1) was protected from involuntary transfer, discharge, and/or eviction. This posed an immediate personal rights risks to persons in care.
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Type B
09/01/2024
Section Cited
CCR
87224(c)
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87224 Eviction Procedures: “(c) The licensee shall, in addition to either serving the required thirty (30) days notice…notify or mail a copy of the notice to quit to the resident's responsible person.” This requirement was not met, as evidenced by:
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Licensee agreed to utilize a third-party source to retrain the facility administrator on RCFE Eviction Procedure requirements (as described in Regulation 87224). Licensee agreed to E-mail the certiifate of training completion (or equivalent proof) to LPA, by the POC due date.
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Based on records review and interviews, for 1 of 6 residents (R1), Licensee evicted them without serving the required thirty (30) days notice to quit to them and their responsible person. This posed a potential personal rights risks 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3