331880645-7-31-2024-18-AS-SJEN-D7PTKX-20240731144841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880645
Report Date: 07/31/2024
Date Signed: 07/31/2024 02:49:02 PM

Document Has Been Signed on 07/31/2024 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BELLA VILLAGGIO		FACILITY NUMBER:	331880645
ADMINISTRATOR:	JIM GERMYN		FACILITY TYPE:	740
ADDRESS:	40235 PORTOLA AVE		TELEPHONE:	(760) 607-5200
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY:	170	CENSUS: 148	DATE:	07/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Eloiza Castellano, administrator		TIME COMPLETED:	03:00 PM

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Licensing Program Analysts (LPAs), Seo Jeon and Javina George made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs were greeted and granted entry to conduct the inspection. On today’s visit the LPAs met with administrator, Eloiza Castellanos and she was notified of the purpose for the visit.

This facility is 2 story building with 148 apartment units, (40 units in memory care and 108 units on the assisted living side). This facility currently has 148 residents including 11 receiving hospice services, 31 dementia, 26 home health, 15 receiving oxygen administration and no bedridden. This facility has maintenance staffs who are in charge of regular cleaning and maintenance. LPA reviewed the facility's infection control plan and found all required infection control measures. There is a separate room Personal Protective Equipment (PPE) supplies.

LPA observed a full service restaurant, movie theater, library, game room, art room, pool table, gym and several lounges. Physical plant, floors, windows, and doors were observed to be clean and in good repair. Fixtures and furniture were in good repair and were present. The outdoor area was observed to have lots of shaded area for clients and was free of hazards. This facility has fenced/gated swimming pool. Cleaning chemicals are all handled by the maintenance staffs. LPA was informed that there is a team of maintenance staffs. The hot water temperature was recorded at 109.9 in room# 107 and 114.0 degrees F in public restroom.

All units are apartments with with kitchen, bathroom and bedrooms. Residents can either dine at the restaurants or receive food services from the facility.

Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff schedule showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The administrator Eloiza Castelleanos does not

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA VILLAGGIO	FACILITY NUMBER: 331880645
	VISIT DATE: 07/31/2024

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possess a valid administrator's certificate as it expired on 7-14-2024. Deficiency cited. Per Eloiza there are still CEUs that need to be completed. In addition a change of Administrator request was submitted in January 2023. However due to there not being a valid administrator certificate, the change of administrator cannot be completed at this time. Once all required documentation is received which includes a valid administrator certificate the change of administrator wiill be made.

LPA reviewed eight(8) staff files and training logs. All staffs have criminal clearance and updated training along with CPR/First Aid Certification. Eight(8) client files were reviewed and possessed all required paperwork.

Medications are stored in a locked cabinet inside a med room with locked door on the first floor. Computerized medication log is maintained. Medications logs were reviewed and they appear to have been dispensed accurately.

LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility performs monthly fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. The smoke and carbon monoxide detectors were tested and observed to be operable. The signal system as also observed to be operable. Fire extinguishers show annual inspection tag.

An exit interview was conducted where a copy of this report, LIC809D and appeals right were provided to administrator, Eloiza Castellanos.

LPAs left the facility at 12:30 pm and returned at 1:25 pm.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/31/2024 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA VILLAGGIO	FACILITY NUMBER: 331880645
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 1 time which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	Administrator will complete CEU by August 9, 2024 and apply for administrator re-certification. It is due by 5:00pm on August 9, 2024. Proof of completion will be emailed to the Department.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

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