331880721-8-15-2024-18-AS-SMAZ-D86SZV-20240815141947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880721
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:19:54 PM

Document Has Been Signed on 08/15/2024 02:19 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 CORTINA RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	331880721
ADMINISTRATOR:	KHAN, SANA		FACILITY TYPE:	740
ADDRESS:	28571 YAROW WAY		TELEPHONE:	(951) 208-4125
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	6	CENSUS: 5	DATE:	08/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Vijethaa Balaji, Co-Administrator		TIME COMPLETED:	02:30 PM

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	Licensing Program Analysts (LPAs), Stephanie Martinez and Armando Perez, conducted a required annual inspection at the facility. The LPAs were allowed entrance into the facility and met with Co-Administrator, Vijethaa Balaji. The LPA informed the Co-Administrator of the purpose for the visit. The inspection included the following: Physical Plant: The facility consists of four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a kitchen and dinning area, a living area, a laundry room, garage, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to the Co-Administrator, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The smoke and carbon monoxide detectors were tested and observed to be in operating condition. The home was kept clean and free of any odors. Food Service: A variety of food was available. Sufficient dinning supplies were available for residents in care. Record Review: Staff responsible for direct care and supervision have current first aid and CPR training. Staff Two (S2) did not have current Dementia training, postural support training or hospice training on file; which are required annual training. S2 had some training related to restricted health Conditions; however, the training was incomplete. No staff file was available for Staff Three (S3) or Staff Five (S5). According to the Co-Administrator, no file was available for S3 because the staff just started working at the facility. According to S3, they have been working at the facility for two days. According to the Co-Administrator, S5 does not have a personnel file due to the individual being a volunteer. She reported S5 has been working for the facility for approximately two weeks. LPAs observed S5 to be present and working at the facility during the

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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 CORTINA RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 331880721
	VISIT DATE: 08/15/2024

NARRATIVE

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visit. S5, however, did not have a fingerprint clearance. According to the Co-Administrator, S5 works at the facility 40 hours per week and does activities with the residents in care. The facility was not operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for two (2) residents and there are currently no residents in care receiving hospice services. There is a disaster and mass casualty plan in place.

Medication Review: The LPA inspected resident medications. Medications were observed to be well organized, labeled and inaccessible to unauthorized individuals.

An exit interview was conducted with the Co-Administrator, in which this report was reviewed and a copy was provided, along with the LIC 811, LIC 9098, LIC 421BG, and instructions on appeal rights

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/15/2024 02:19 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 CORTINA RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 331880721
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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] staff members who did not have the required training completed. S2 did not have current Dementia training, postural support training or hospice training on file. S2 had 1.25 hours of restricted healthcare training. This violation poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	The Co-Administrator stated the training for S2 will be completed and proof of the training will be submitted to the Department by the POC due date.

Type B

Section Cited

CCR

87412(f)

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in [2] out of [5] staff files that were not available. No staff file was available for S3 or S5. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Co-Administrator stated files will be created for both staff members and photographs will be submitted to the Department by the POC due date.

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: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/15/2024 02:19 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 CORTINA RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 331880721
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.17(b)(1)(D)

Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances In addition to the applicant, the provisions of this section shall apply to criminal record clearances and exemptions for the following persons: Any staff person, volunteer, or employee who has contact with the clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in [1] out of [4] staff members who did not have an appropriate criminal record clearance prior to working in the facility. LPAs observed S5 to be present and working at the facility; however, the individual did not have a fingerprint clearance. This poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 08/15/2024
	Plan of Correction
1 2 3 4	LPAs observed S5 leave the facility prior to the end of their visit. POC cleared.

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: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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