336426549-10-30-2024-18-AS-SMAZ-DAK2TY-20241030174132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426549
Report Date: 10/30/2024
Date Signed: 10/30/2024 05:41:40 PM

Document Has Been Signed on 10/30/2024 05:41 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:	AQUA BELLA RESIDENTIAL CARE		FACILITY NUMBER:	336426549
ADMINISTRATOR/ DIRECTOR:	MUSARRAT KHAN		FACILITY TYPE:	740
ADDRESS:	14736 WILLOW GROVE PLACE		TELEPHONE:	(951) 208-1825
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	10/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:23 PM
MET WITH:	Musarrate Khan, Administrator/Licensee		TIME VISIT/ INSPECTION COMPLETED:	05:50 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 Analyst (LPA), Stephanie Martinez, conducted a required annual inspection to the facility. The LPA was allowed entrance into the facility and met with Administrator, Musarrate Khan. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: Physical Plant: The facility consists of five (5) resident bedrooms, two and one half (2 1/2) bathrooms, one (1) staff room, a kitchen and dinning areas, a living room area, a garage, and a yard and patio with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Khan, 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 obstruction and are 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 carbon monoxide and smoke detectors were tested and were observed to be in operating condition. The home was kept clean, organized and free of any odors. Food Service: There is a minimum of two (2) days supply of perishable foods and one (1) week's supply of non-perishable foods available. Sufficient dinning supplies were available for residents in care. A variety of food was observed to be available. Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care and medication training was observed to be complete. Resident files had admission agreements and medical assessments available for review. One of six residents did not have an updated medical assessment on file. Resident Six (R6), whose health condition requires an annual medical assessment last had an evaluation on 10/04/2019. According to Administrator Khan, no

Rikesha Stamps	TELEPHONE: (951) -212-0616
Stephanie Martinez	TELEPHONE: (951) 204-5924
	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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: AQUA BELLA RESIDENTIAL CARE	FACILITY NUMBER: 336426549
	VISIT DATE: 10/30/2024

NARRATIVE

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previous medical assessments were requested for the resident until October 2024. A citation will be issued. In addition, one of six residents did not have an updated written record of care. The last written record of care for Resident Six (R6) was dated 06/08/2021. According to Administrator Khan, no updated record of care was completed for the resident. A citation will be issued.

The facility was not operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for two residents and there is currently one residents in care receiving hospice services. The LPA observed current liability insurance on file.

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

Technical Assistance and Technical Violations were issued to Administrator Khan for other, non-immediate, violations observed during the LPA's visit.

Administrator Khan agreed to provide the LPA with a copy of the current liability insurance, proof of control of property, a staff schedule, and a resident roster to update the facility file.

An exit interview was conducted with the Administrator, in which this report was reviewed and a copy was provided, along with the LIC 811, LIC 9098, 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: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/30/2024 05:41 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: AQUA BELLA RESIDENTIAL CARE	FACILITY NUMBER: 336426549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87467(a)(3)

Resident Participation in Decisionmaking

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. 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 in 1 out of 6 residents who did not have a written record of care. According to Administrator Khan, no updated record of care was completed for the resident. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 11/13/2024
	Plan of Correction
1 2 3 4	Administrator Khan stated she will arrange a meeting with the resident and the resident's representative to create a written record of care and will submit a copy 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: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/30/2024 05:41 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: AQUA BELLA RESIDENTIAL CARE	FACILITY NUMBER: 336426549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia: Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. 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 in 1 out of 6 residents who did not have a medical assessment completed within 1 year. According to Administrator Khan, no previous medical assessments were requested for the resident until October 2024. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 11/30/2024
	Plan of Correction
1 2 3 4	Administrator Khan stated a new medical assessment has already been requested. She stated a copy of the medical assessment would be provided to the Department by the 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: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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