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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610053
Report Date: 12/07/2022
Date Signed: 01/12/2023 03:30:53 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2021 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20210909164422
FACILITY NAME:BELLA NOVA VILLA IIFACILITY NUMBER:
567610053
ADMINISTRATOR:AYALA, MARIA S.FACILITY TYPE:
740
ADDRESS:1720 CORONADO PLACETELEPHONE:
(805) 242-6682
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 6DATE:
12/07/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Maria AyalaTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Resident requires a higher level of care
Staff not adequately trained
Insufficient staffing to meet resident needs
INVESTIGATION FINDINGS:
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This is an amended report for the report issued on 12/207/2022. Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver the final findings to the above facility. LPA met with Administrator Maria Ayala at 9:35 a.m. Entrance interview conducted.

On 09/09/2021, the Department received a complaint which alleged that R1 requires a higher level of care. On 11/17/2022, interview with Administrator Maria Ayala starting at 12:35 p.m. revealed that Resident #1 (R1) was admitted to the facility on 07/01/2021 with open sores on their buttocks and back. R1 was receiving hospice services prior to the arrival at the facility. Interview with R1’s family member on 12/5/2022 and 1/10/2023, revealed that upon R1’s admission to the facility, R1 was on hospice with Stage 2 and 3 open sores on back, legs and buttocks. As such, the wounds were present prior to their admission to the facility and were cared for by an appropriately skilled professional.

Continued on LIC 9099 - C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
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 29-AS-20210909164422
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLA NOVA VILLA II
FACILITY NUMBER: 567610053
VISIT DATE: 12/07/2022
NARRATIVE
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On 7/25/2021, it was noted that R1 experienced a change of condition. Interviews with R1’s family member and the Administrator revealed that R1 appeared lethargic, was not eating and was refusing medication. A review of hospice chart notes, on 12/7/22 starting at 8:15 a.m., revealed that on 07/25/2021, the hospice nurse, R1’s family member and the Administrator agreed to revoke hospice services and send R1 to the hospital. Upon admittance to the hospital, it was discovered that R1 was diagnosed with pneumonia. From the hospital, R1 was then transferred to a skilled nursing facility. The family indicated that R1’s pressure injuries worsened at the skilled nursing facility, and R1 sent back to the hospital for treatment of the injuries. R1 eventually was re-admitted to Bella Nova II on 09/04/2021. R1’s family member added that the hospital gave them a choice of going back to the skilled nursing facility or back to the facility. R1’s family member decided to move R1 back into Bella Nova Villa II on 09/04/2021. When R1 was re-admitted to Bella Nova II, R1 was also re-admitted to hospice services. Further review of hospice documentation revealed that on 09/04/2021, R1 was re-admitted to hospice services with a diagnosis of Alzheimer’s Disease, pressure ulcer of other site unspecified stage, and eight (8) other medical conditions. R1 passed away on 09/13/21.

Interview with hospice worker on 01/09/2023, starting at approximately 1:18 p.m., could not provide substantial evidence that R1 needed a higher level of care, but stated that their concern was one (1) care staff was present while at the facility during a visit. However, per interviews conducted with staff, there was insufficient evidence gathered to support the claim that R1 did not receive adequate care. Although R1 was sent to the hospital and was treated for pneumonia, interviews and documentation indicated that there was no change of condition in which R1 required a higher level of care while at Bella Nova II. Based on evidence gathered, the allegation resident requires a higher level of care is deemed unsubstantiated at this time.

Also being alleged is insufficient staffing to meet resident needs. On 09/17/2021, LPA Kelly Dulek conducted a facility tour starting at approximately 10:30 a.m. and observed two (2) staff present. On 11/17/2022, LPA Ascencio conducted a facility tour starting at 12:15 p.m. and observed two (2) staff members present at the facility. LPA Ascencio also observed six (6) resident that appeared to be clean, and well-taken care for. LPA observed residents asking to use the restroom and staff members attending to the needs of the residents. LPA also observed resident bedrooms that were set up with beds with clean linen. Appliances in the kitchen were clean. All rooms were free of odors and appeared clean. At the time of visit, LPA also observed meals being prepared and served to residents in a timely manner.

Continued on LIC 9099 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210909164422
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLA NOVA VILLA II
FACILITY NUMBER: 567610053
VISIT DATE: 12/07/2022
NARRATIVE
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Later that same day, interview with Administrator Maria Ayala, starting at 12:35 p.m., revealed that 2 staff members are always present in the morning, evening and night at the facility to assist with resident needs. Administrator Maria also informed LPA that there are ten (10) staff members that rotate and work at the facility. LPA attempted to interview six (6) residents; however, due to their medical diagnosis, the LPA was unable to obtain sufficient information. Interviews with staff members on 09/17/2021, 11/17/2022, 01/11/2023 and 01/12/2023 revealed that they believe they have sufficient staffing at morning, evening and night, to meet the needs of the residents. Additionally, staff stated that there are 2 residents that require 2-person assist and the staffing they have is sufficient to meet those needs. Staff stated that resident mealtimes are morning, lunch and dinner. Staff assist resident up from their beds, help provide toileting needs, shower, clothes and transportation to the dining room every morning. Residents are also given snacks in between their meals. Staff stated residents are checked and changed frequently based on their hygienic needs and after every meal. Also, staff stated that after residents have lunch, most of the residents like to take a nap. Staff use this time to stagger their 30-minute break. Staff interviews supported the claim that there was at least two staff members present during the morning and evening shift. However, in order to maintain sufficient coverage, staff will stagger their 30-minute break time in which resident care is at a minimal. However, staff stated although they are on break, they are available to assist the other staff on duty in the case of emergencies. Based on interviews, observation and record review, the allegation insufficient staffing to meet resident needs is deemed unsubstantiated at this time.

Lastly, it is also being alleged that staff are not adequately trained. During facility visit on 11/17/2022, LPA Ascencio reviewed seven (7) staff member files. LPA observed all seven staff members have their initial and annual training that includes: first aid, personal care services, medication training, resident rights, psychosocial needs of the elderly and dementia training. LPA observed documents that stated Administrator Maria conducted training for staff members in 2016 until present. LPA Ascencio also observed specialized training such as infection control and hoyer lift training for all seven (7) staff members. Later that same day, interview with Administrator Maria Ayala starting at 12:35 p.m. revealed that Administrator Maria conducts video training, shadow training and one on one training with all staff when the staff gets hired and on a monthly basis. Administrator Maria also added they are a Licensed Vocational Nurse (LVN) and conducts medication training with all of their staff upon hire. LPA obtained monthly training for all staff in 2022. Based on record review and observation, the allegation staff are not adequately trained is deemed unsubstantiated at this time.

Exit interview conducted. Administrator stated an email copy is preferred. LPA emailed copy to Administrator.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3