331880721-8-29-2023-18-AS-JROO-CV6SEB-20230829134829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880721
Report Date: 08/29/2023
Date Signed: 08/29/2023 01:48:35 PM

Document Has Been Signed on 08/29/2023 01:48 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 AC/SC, 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:	08/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Caregiver Deborah Johnston		TIME COMPLETED:	02:00 PM

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On 8/29/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Deborah Johnston who was informed of the purpose of visit. During the visit, there was three (3) residents and one (1) staff present, and LPA was informed two (2) residents were out in the community.

The facility is approved to care for six (6) non-ambulatory residents and has a hospice waiver for two (2). LPA toured the facility's interior and exterior. During the visit, LPA observed the following:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. The facility had a 2-day supply of perishable food items and 7-day supply of non-perishable food items. Knives/sharp instruments are secured in a locked kitchen cabinet.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. A fire extinguisher was charged and mounted in the living room.

Hallway: LPA observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detector were tested and functioning properly.

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA CORTINA RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 331880721
	VISIT DATE: 08/29/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a cabinet near the kitchen. LPA reviewed physical medications for the Resident #1 and Resident #2 as well as the Medication Administration Record (MAR) used to log administration of residents’ medications. LPA found that Staff #1 dispensed medication for all residents this morning (8/29/2023) and did not document assistance with medication on MAR. Deficiency cited.

Bedrooms: Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 117- and 118-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care.

Laundry/Garage: LPA observed laundry room and garage to be clean. Washing machine and dryer are in good repair. Cleaning solutions and chemicals are secured in locked garage cabinet. Emergency food supplies, water, and incontinent supplies are stored in the garage.

Records: Staff #1 (S1) present has a criminal record clearance on file and is associated to the facility. S1's CPR/First Aid certification expired on 4/27/2023. Deficiency cited.

Yard/Outside Area: Covered patio seating is available for residents. A vinyl fence secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

LPA did not observed two (2) deficiencies faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to Caregiver Johnston along with an LIC809-D and Appeals Rights.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2023 01:48 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 AC/SC, 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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above due to record review and interview revealing the CPR/First Aid certification for Staff #1 is expired, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Licensee agreed to request Staff #1 to obtain CPR/First Aid certification and provide proof of correction to CCLD by close of business on POC due date.

Type B

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above due to LPA finding that staff dispensed medication this morning (8/29/2023) and did not document assistance with medication on MAR, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide staff training regarding medication management, dispensing and documentation, and provide proof of correction to CCLD by close of business on 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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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