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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880721
Report Date: 08/19/2021
Date Signed: 08/19/2021 04:32:26 PM

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 CORTINA RESIDENTIAL CARE FACILITYFACILITY NUMBER:
331880721
ADMINISTRATOR:KHAN, SANAFACILITY TYPE:
740
ADDRESS:28571 YAROW WAYTELEPHONE:
(951) 208-4125
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 6DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Evelyn MercadoTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with Evelyn Mercado and licensee/ administrator Sana Khan arrived during the visit. LPA advised Ms. Khan of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only.
LPA went over COVID-19 best practices for infection control and prevention with Ms. Khan who are successfully incorporating the facility's Mitigation Plan. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA advised Ms. Khan that the paper towels need to be on a stand. LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated.
LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. And in a large storage area for storing all PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to residents.
LPA inquired as to if staff have been fit tested for N95 masks, and Ms. Ms. Khan stated their staff have not been fit tested yet. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. Additionally, all of the residents have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA provided Ms. Khan with the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.
An exit interview was conducted, and this report was discussed and provided to Ms. Khan along with a copy of PIN 21-10-ASC and LIC9102 TA Advisory Note.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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