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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700710
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:45:49 PM


Document Has Been Signed on 03/10/2022 03:45 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:BELLA NOVA RCFEFACILITY NUMBER:
342700710
ADMINISTRATOR:TEDLOS, BRIANFACILITY TYPE:
740
ADDRESS:8797 TWINBERRY WAYTELEPHONE:
(916) 667-3248
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
03/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Mary Deleon, CaregiverTIME COMPLETED:
04:00 PM
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On 03/10/2022, Licensing Program Analysts (LPAs),T. White and R. Campbell, conducted an unannounced case management visit to follow up on an AWOL incident, which occurred on 02/25/2022. LPAs met with Caregiver, Mary Deleon and explained the purpose of the visit.

LPA White reviewed the incident report submitted to CCLD on 03/01/2022. Based on incident report, Staff #1 (S1) found Resident #1 (R1) a few houses down and R1 came back to facility 10-15 minutes later. Based on S1's interview, R1 was sitting on the porch and S1 came in the house to check dinner. S1 went back outside to check on R1 and observed R1 was not sitting on the front porch. S1 stated she informed the Administrator and the Administrator contacted law enforcement. Law Enforcement came to the facility and spoke with R1 and conducted a wellness check Based on R1's Physician Report (LIC602), it does not stated if R1 is able to leave unassisted. S1 stated R1 is unable to leave unassisted.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview was conducted with Caregiver. A copy of report and Appeal rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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Document Has Been Signed on 03/10/2022 03:45 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: BELLA NOVA RCFE
FACILITY NUMBER: 342700710

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2022
Section Cited

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87411(a)- Personnel Requirements - General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement is not met by observation and records review
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Based on documentation and interview, facility did not comply to section cited in 87411(a). Based on interviews conducted and records reviewed, the facility did not ensure R1 was appropriately supervised, resulting in R1’s AWOL which posed an immediate health, safety, and personal rights risk to the residents in care.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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