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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880645
Report Date: 02/28/2022
Date Signed: 02/28/2022 04:05:11 PM

Document Has Been Signed on 02/28/2022 04:05 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BELLA VILLAGGIOFACILITY NUMBER:
331880645
ADMINISTRATOR:JIM GERMYNFACILITY TYPE:
740
ADDRESS:40235 PORTOLA AVETELEPHONE:
(760) 607-5200
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY: 170CENSUS: 129DATE:
02/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Guest Services Manager, Stephanie FrattaroliTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Jennifer Semin conducted a case management in conjunction with complaint control number 18-AS-20200629105748. LPA met with Guest Services Manager, Stephanie Frattaroli.

LPA requested to review Resident 1's (R1's) file. Staff stated they were unable to locate R1's medical file. Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by: Resident 1's complete file was unavailable to be reviewed by LPA. This poses a potential risk to residents in care. A deficiency will be cited.


An exit interview was conducted where this report, LIC809D, and appeal rights were discussed and provided to Stephanie Frattaroli.



SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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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Document Has Been Signed on 02/28/2022 04:05 PM - It Cannot Be Edited


Created By: Jennifer Semin On 02/28/2022 at 03:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA VILLAGGIO
FACILITY NUMBER: 331880645

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2022
Section Cited
CCR
87506(e)

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Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by: Resident 1's complete file was unavailable to be reviewed by LPA. This poses a potential risk to residents in care.
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Licensee shall read the regulation in it's entirety, train staff, submit a statement of understanding and a training log to CCL by the POC due date of 3/7/2022.

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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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Jennifer Semin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022


LIC809 (FAS) - (06/04)
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