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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880645
Report Date: 02/28/2022
Date Signed: 02/28/2022 04:04:30 PM

Substantiated


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
06/29/2020 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200629105748
FACILITY NAME:BELLA VILLAGGIOFACILITY NUMBER:
331880645
ADMINISTRATOR:WIERINGA, DIERDRE (DEE)FACILITY TYPE:
740
ADDRESS:40235 PORTOLA AVETELEPHONE:
(760) 607-5200
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:170CENSUS: 129DATE:
02/28/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Guest Services Manager, Stephanie FrattaroliTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not notify resident's authorized representative of changes in health condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegation. LPA met with Guest Services Manager, Stephanie Frattaroli
The investigation consisted of interviews and review of records. The allegation, Staff did not notify resident's authorized representative of changes in health condition. Staff stated that Resident 1’s (R1’s) primary care physician (PCP) and responsible party (RP) were notified regarding R1’s change in condition. Facility documents indicate PCP was notified. There are no facility documents indicating the RP was notified. RP stated they were not contacted by the facility regarding R1’s change in condition. PCP was unable to be contacted refute or corroborate or refute the allegation.
Based on interviews and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.
An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to Stephanie Frattaroli.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
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.
LIC9099 (FAS) - (06/04)
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Control Number 18-AS-20200629105748
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2022
Section Cited
CCR
87466
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OBSERVATION OF RESIDENT
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a
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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 .5/21/2022.
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physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement was not met as evidence by: the faciltiy could not provide any documentation that the responsible party was notifed for R1's change in condition This poses a health and safety risk to residents in care.
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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 ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
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