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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604790
Report Date: 09/23/2024
Date Signed: 09/23/2024 03:15:35 PM

Unsubstantiated


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: 5DATE:
09/23/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caregiver Marisela Torno and Administrator Cherry CookTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Licensee did not offer resident social interaction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Marisela Torno. LPA also spoke with Adminisrator Cherry Cook via phone.

The Complainant alleged that Licensee did not offer Resident #1 (R1) social interaction. CCLD’s investigation involved unannounced facility tours, review of pertinent care records and activities schedule, and interviews of pertinent facility staff, residents, and outside sources.

Licensee possessed a sample schedule of activities. Staff interviews generally showed: In practice, staff modified/adjusted the offerings as as needed to fit the abilties and interests of the residents in care. Some of the residents had lengthly outside commitments, such as attending day program or dialysis treatment, several days per week. [CONTINUED ON LIC 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
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 2
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: 09/23/2024
NARRATIVE
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[CONTINUED FROM LIC 9099] Resident interview showed: Residents had freedom in choosing their activities, staff socialized with them, and they had enough activities to keep them entertained when they were at the facility.

According to care records, and corroborated by staff and outside source interviews: During the timeframe of the allegation, R1 was diagnosed with “Dementia,” “Senlie Degeneration of the Brain,” “CVA residual hemiplegia,” and “left elbow amputation,” among other conditions. R1 was concurrently under the care of a visiting hospice agency for end-of-life care. R1 spent their days in bed, and was not physically capable of partaking in activities outside of their bedroom with their housemates. By the date the Department received the complaint, R1 had already moved out of the facility. However, during a prior site visit on 05/02/2024, LPA had observed facility staff visit with R1 bedside, treating them with kindness.

Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not offer R1 social interaction. The allegation is therefore Unsubstantiated, and no deficiency was cited.

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

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
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