331880645-7-24-2020-18-AS-EMAN-BRZP8Y-20200730110620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880645
Report Date: 07/02/2020
Date Signed: 07/24/2020 11:36:17 AM

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
05/18/2020 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200518150442

FACILITY NAME:	BELLA VILLAGGIO		FACILITY NUMBER:	331880645
ADMINISTRATOR:	WIERINGA, DIERDRE (DEE)		FACILITY TYPE:	740
ADDRESS:	40235 PORTOLA AVE		TELEPHONE:	(760) 607-5200
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY:	170	CENSUS: 84	DATE:	07/02/2020
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Jim Germyn		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff had resident taken to the emergency room without resident's consent
Staff threatened resident
Staff failed to assist resident with dressing and being put to bed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Stephanie Williams contacted the facility to deliver findings for the above allegations via telephone due to the COVID-19 pandemic. LPA identified herself and discussed the purpose of the call with General Manager, Jim Germyn. The investigation consisted of interviews with staff/clients and records review.

In regards to allegation #1, LPA interviewed Resident #1 (R1) who stated that emergency services were called on 3/26/20 but R1 was not taken to the emergency room. LPA interviewed staff members who stated that they contacted 911 as advised by a Riverside County Public Health representative; however, R1 was not taken by the paramedics or forced to go to the emergency room by facility staff.

In regards to allegation #2, LPA interviewed staff who denied threatening R1. Staff stated that they were explaining to R1 why 911 was being contacted; however, they did not threaten to call law enforcement if he did not comply. LPA reviewed documentation from the facility in which it was indicated that a Riverside

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2020

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 18-AS-20200518150442

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 VILLAGGIO	FACILITY NUMBER: 331880645
	VISIT DATE: 07/02/2020

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
26
27
28
29
30
31
32

County Public Health representative stated they would contact law enforcement if the facility did not call 911 due to R1's condition.

In regards to allegation #3, LPA interviewed R1 who stated that a staff member assisted R1 with dressing on the night of 3/26/20. LPA interviewed Staff #1 (S1) and Staff #2 (S2) who both stated that R1 refused assistance with dressing during their shift. R1 reportedly told S1 and S2 he would call once he was ready for bed. S1 and S2 stated that he called staff around 11:00PM where the noc shift staff helped R1 change and get ready for bed.

Based on evidence obtained from the facility, LPA has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited during this visit. An exit interview was conducted where this report was discussed and a copy was provided via email to Germyn.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2