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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700710
Report Date: 09/08/2022
Date Signed: 09/08/2022 11:17:18 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2022 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20220725085115
FACILITY NAME:BELLA NOVA RCFEFACILITY NUMBER:
342700710
ADMINISTRATOR:KHAN, SHAHBAZFACILITY TYPE:
740
ADDRESS:8797 TWINBERRY WAYTELEPHONE:
(916) 667-3248
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
09/08/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Shahbaz Khan, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility does not have a posted sample menu
Facility is not proving well balanced meals
Facility does not provide meals with consideration to the religious background of a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 9/8/22 at 9:40 am to deliver findings for this complaint. LPA met with Administrator Shahbaz Khan and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on statements obtained and LPA’s observation, it was observed that the facility has a posted sample menu. Moreover, facility staff stated that residents are provided with well balanced meals. The weekly menu revealed that fruits and vegetables were included in meals. In addition, resident (R3) stated food is good and there are different varieties of foods for lunch and dinner. Furthermore, it was learned that the facility had taken into consideration in providing meals to resident with religious background.

Report continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20220725085115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/08/2022
NARRATIVE
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As a result of this investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2