335530124-9-10-2024-56-AS-ESEO-D8YVE9-20240910162158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530124
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:23:53 PM

Document Has Been Signed on 09/10/2024 04:23 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BELLA CAI CARE HOME		FACILITY NUMBER:	335530124
ADMINISTRATOR:	ABDULLAH, SITI KHATIJAH		FACILITY TYPE:	740
ADDRESS:	29111 OAK GROVE WAY		TELEPHONE:	(562) 537-8885
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	6	CENSUS: 5	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Charise Magsaysay Licensee/Administrator		TIME COMPLETED:	04:30 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	On 9/10/2024 at 09:25 AM, Licensing Program Analysts (LPA) Melody Brown and Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPAs Brown and Serrano met with Licensee/Administrator Charisse Magsaysay and was granted entry to the facility. At the time of the visit there were two (2) staff present, and five (5) residents present. The facility is a five (5) bedrooms, five (3.5) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory and six (6) hospice care and 1 maybe bedridden resident and the current census is five (5) residents. LPAs Brown and Serrano was accompanied by Staff #3 to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPAs Brown and Serrano inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs Brown and Serrano observed sufficient furniture and lighting throughout the facility. LPAs Brown and Serrano measured and observed the water temperatures in the bathroom to be at 107 degrees F at Room # 5. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, labor laws, and the disaster plan were posted in a common area. LPAs Brown and Serrano observed resident 2 (R2) and resident 3 (R3) have half bed rails. Licensee/Administrator Magsaysay reported to LPAs Brown and Serrano that R2 and R3 do not have written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. continuation on LIC 809C

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA CAI CARE HOME	FACILITY NUMBER: 335530124
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 by not ensuring that staff 4 (S4) complete the required health screening report which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	Licensee submitted proof of S4 completed health screening report which was obtained during the visit today, 9/10/2024. Plan of correction (POC) cleared.

Type A

Section Cited

CCR

87412(a)(12)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General. 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 by not ensuring that Staff 4 (S4) complete the required tubeculosis (TB) test which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	Licensee submitted proof of S4 completed TB test result which was obtained during the visit today, 9/10/2024. Plan of correction (POC) cleared.

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	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA CAI CARE HOME	FACILITY NUMBER: 335530124
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(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 observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring that staff 2 (S2) and staff 3 (S3) have the required first aid training from a agency such as Red Cross which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit S2 and S3 proof of first aid training to LPA Serrano on plan of correction (POC) due date.

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 by not ensuring that resident 1 (R1) and resident 3 (R3) medications were given per their physicians directions as evidenced of resident 1 (R1) four (4) medications were not given per R1 physicians order. Also, LPAs observed resident 3 (R3) one (1) medication was not given per R3 physicians order. Moreover, LPAs observed R3 one (1) medication was not refilled on time, thus not given per R3's physician order, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87465(c)(2) and submit proof of staff training log to LPA Serrano on POC due date. Licensee conducted the required training during the visit today, 9/10/2024. POC cleared.

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	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA CAI CARE HOME	FACILITY NUMBER: 335530124
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 by not ensuring that resident 3 (R3) has completed physician report /medical assessment on R3 file as evidence of R3's physician report does not have the required physician signature date which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	LIcensee stated to submit a copy of R3 completed physician report/appointment to complete with the required physician signature date to LPA Serrano on plan of correction (POC) due date.

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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA CAI CARE HOME	FACILITY NUMBER: 335530124
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(17)(A)

Resident Records

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; 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 by not completing the required pre-admission appraisal for resident 1 (R1) and resident 3 (R3) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Licensee submitted the statement of understanding on CCR 87506(b)(17)(A). POC cleared.

Type B

Section Cited

HSC

1569.695(a)(2)

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. 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 by not ensuring that the facility has the emergency supply kits, emergency food and water as required which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain/purchase emergency supply kits and emergency food and water and submit proof to LPA Serrano on 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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA CAI CARE HOME	FACILITY NUMBER: 335530124
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. 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 by not completing the required needs and services plan for resident 1 (R1), resident 2 (R2) and resident 3 (R3) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Licensee submitted the required the required needs and assessment plan for R2 and R3 during the visit. POC cleared.

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 by allowing that resident 2 (R2) and resident 3 (R3) to have half bed rails without obtaing a written order from their physician indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain the required wirtten order form R2 and R3 physicain indicating the need for the half bed rail for mobility and submit proof to LPA Serrano 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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA CAI CARE HOME	FACILITY NUMBER: 335530124
	VISIT DATE: 09/10/2024

NARRATIVE

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Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Closet with the resident’s medications locked. LPAs Brown and Serrano observed complete first aid kit and first aid book at the facility.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Also, LPAs Brown and Serrano observed that the facility does not have dementia residents.

Record Review: LPAs Brown and Serrano reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and centrally stored medication list and needs and services plans. LPAs Brown and Serrano observed that resident 1(R1) and resident 3 (R3) do not have the required pre-placement appraisal in their facility file. Deficiency will be issued. LPAs Brown and Serrano observed resident 3 (R3) physician report does not have a physician signature date. Deficiency will be issued. LPAs Brown and Serrano observed that resident 1 (R1), resident 2 (R2), resident 3 (R3) do not have the required needs and services plan. Deficiency will be issued. LPAs Brown and Serrano reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings and tuberculosis (TB) test. LPAS Brown and Serrano observed that staff 4 (S4) does not have the required health screening report and TB test. Deficiency will be issued. During the visit S4 complete the required health screening report and TB test. Medications/Medication Administration Record (MAR) were audited, and LPAs Brown and Serrano observed resident 1 (R1) four (4) medications were not given per R1 physicians order. Also, LPAs observed resident 3 (R3) one medication was not given per R3 physicians order. Moreover, LPAs observed R3 one (1) medication was not refilled on time, thus not given per R3's physician order. Deficiency will be issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809, LIIC809D, LIC9102 forms, and Appeal Rights were discussed and provided to Licensee/Administrator Charisse Magsaysay

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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