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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800425
Report Date: 12/05/2020
Date Signed: 12/07/2020 08:01:00 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2019 and conducted by Evaluator Stephanie Torres
COMPLAINT CONTROL NUMBER: 18-AS-20190910080854
FACILITY NAME:BELLA GARDEN RESIDENTIAL SENIOR CAREFACILITY NUMBER:
361800425
ADMINISTRATOR:MEZA-BROWN, ELIZABETHFACILITY TYPE:
740
ADDRESS:22790 VAN BUREN STREETTELEPHONE:
(909) 285-7878
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:6CENSUS: 6DATE:
12/05/2020
UNANNOUNCEDTIME BEGAN:
05:36 PM
MET WITH:Administrator, Elizabeth Meza-BrownTIME COMPLETED:
05:56 PM
ALLEGATION(S):
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Facility staff issued an illegal eviction.


INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone call to deliver the findings on the above allegation via telephone due to COVID-19. The LPA identified herself and discussed the purpose of the call with Administrator, Elizabeth Meza-Brown.

Regarding the allegation, "Facility staff issued an illegal eviction," it was alleged Administrator, Meza-Brown, issued an eviction notice to Resident One (R1) which lacked no facts, no list of providers or rights to file a complaint. The LPA conducted staff and resident interviews, reviewed records, and took copies of pertinent information. According to Meza-Brown, R1 and their authorized representative were served both a three (3) day and thirty (30) day eviction notice due to failure to pay rent. Both a 3-Day Notice to Pay Rent or Vacate Premises and a 30/60 Day Notice of Termination of Tenancy were observed on file. According to the 3-day eviction notice, rent for R1 was due August 01, 2019 through August 31, 2019, in the amount of $1,884.00. Neither of the eviction notices, dated August 14, 2019, included resources available to assist R1 in identifying alternative housing/care options or a statement informing R1 of their right to file a complaint. This posed a
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2020
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2019 and conducted by Evaluator Stephanie Torres
COMPLAINT CONTROL NUMBER: 18-AS-20190910080854

FACILITY NAME:BELLA GARDEN RESIDENTIAL SENIOR CAREFACILITY NUMBER:
361800425
ADMINISTRATOR:MEZA-BROWN, ELIZABETHFACILITY TYPE:
740
ADDRESS:22790 VAN BUREN STREETTELEPHONE:
(909) 285-7878
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:6CENSUS: 6DATE:
12/05/2020
UNANNOUNCEDTIME BEGAN:
05:36 PM
MET WITH:Administrator, Elizabeth Meza-BrownTIME COMPLETED:
05:56 PM
ALLEGATION(S):
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Facility staff is disclosing resident's confidential information.
Facility staff is using camera and audio in the facility.
Facility staff are not allowing visitors into the home.
Facility staff did not provide responsible party a copy of the admission's agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone call to deliver the findings on the above allegations via telephone due to COVID-19. The LPA identified herself and discussed the purpose of the call with Administrator, Elizabeth Meza-Brown.

Regarding the allegation, "Facility staff is disclosing resident's confidential information," it was alleged Administrator, Meza-Brown, in December 2018, disclosed confidential information relating to the health conditions of the resident's in care. The LPA conducted staff/resident interviews, reviewed records and took copies of pertinent information. Administrator, Meza-Brown, was interviewed and denied any confidential information had been disclosed to any unauthorized individuals. It was alleged witnesses were present when the confidential information was disclosed, however, names or contact information for those individuals could not be provided. Interviews could not coroborate or refute the allegation took place. This allegation is deemed UNSUBSTANTIATED at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20190910080854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BELLA GARDEN RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 361800425
VISIT DATE: 12/05/2020
NARRATIVE
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With regard to the allegation, "Facility staff is using camera and audio in the facility," it was alleged Administrator, Meza-Brown, utilizes audio and visual cameras inside and outside of the facility. Staff interviews reported surveillance devices were being utilized inside and outside of the facility. Interviews reported the devices were not recording private areas of the facility. According to Administrator, Meza-Brown, the devices do not record audio inside the facility. Documentation was requested on the type of devices used, and whether or not they can audio record, however it could not be provided by the Administrator. Furthermore, the Department does not prohibit surveillance devices to be utilized in areas that are readily viewable/accessible by the public. This allegation is deemed UNSUBSTANTIATED at this time.

Pertaining to the allegation, "Facility staff are not allowing visitors into the home," it was alleged R1's family and friends were not allowed to visit with the resident. According to Administrator, Meza-Brown, a restraining order was requested to limit the visitation of two (2) of R1's relatives due to behaviors which caused a hostile work environment for facility staff and residents in care. Meza-Brown stated no other family or friends were restricted from visiting R1. A Notice of Court Hearing report, dated September 25, 2019 was obtained. The report indicates Meza-Brown petitioned for a Temporary Restraining Order, which was approved, against two (2) of R1's family members pending a hearing date of October 16, 2019. One staff reported R1 was permitted to have visitors until the Restraining Order was established. R1 was interviewed on September 9, 2019, and reported they are able to visit with the two (2) family members in question.. R1 is diagnosed with a cognitive impairment. No details could be provided regarding incidences in which R1 was not allowed to have visits from other family/friends. This allegation is deemed UNSUBSTANTIATED at this time.

With regard to the allegation, "Facility staff did not provide responsible party a copy of the admission's agreement," it was alleged R1's responsible party did not receive a copy of the Admission Agreement established for R1. An Admission Agreement was observed on file for R1, dated December 02, 2018. No receipt of the Admission Agreement by R1's responsible party was observed on file. According to Administrator, Meza-Brown, a copy of the agreement was provided to the responsible party. This allegation is deemed UNSUBSTANTIATED at this time.

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(s) occurred. This report was reviewed with Administrator, Meza-Brown, and a copy was provided.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2019 and conducted by Evaluator Stephanie Torres
COMPLAINT CONTROL NUMBER: 18-AS-20190910080854

FACILITY NAME:BELLA GARDEN RESIDENTIAL SENIOR CAREFACILITY NUMBER:
361800425
ADMINISTRATOR:MEZA-BROWN, ELIZABETHFACILITY TYPE:
740
ADDRESS:22790 VAN BUREN STREETTELEPHONE:
(909) 285-7878
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:6CENSUS: 6DATE:
12/05/2020
UNANNOUNCEDTIME BEGAN:
05:36 PM
MET WITH:Administrator, Elizabeth Meza-BrownTIME COMPLETED:
05:56 PM
ALLEGATION(S):
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Facility staff took resident's records off the facility premises.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone call to deliver the findings on the above allegations via telephone due to COVID-19. The LPA identified herself and discussed the purpose of the call with Administrator, Elizabeth Meza-Brown.

Regarding the allegation, "Facility staff took resident's records off the facility premises," it was alleged Resident One's (R1's) records were not being retained on the facility premesis, on or around August 16, 2019, resulting in an authorized representative from not having access to the records. The LPA conducted staff/resident interviews, reviewed records, and took copies of pertinent information. Staff interviews reported resident records have not been removed from the premesis and remain securred from unauthorized personnel. According to Administrator, Meza-Brown, R1's records were not removed from the facility. On September 19, 2019, the LPA observed R1's file on the premesis and was able to gain access to the records. The individual who made the request was interviewed and reported they did have access to R1's file. Therefore, the allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

This report was reviewed with Administrator, Meza-Brown, and a copy was provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 18-AS-20190910080854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA GARDEN RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 361800425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2020
Section Cited
CCR
87224(d)(1)
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EVICTION PROCEDURES: The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. The notice to quit shall include the following information: Based on records
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The Administrator agreed to submit to the Department a statement indicating Eviction Procedures (87224) were read and understood.
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 review, the Licensee did not ensure the eviction notices included required information. Neither the 3-day or 30/60 day eviction notices included resources available to assist R1 in identifying alternative housing/care options or a statement informing R1 of their right to file a complaint.
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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: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20190910080854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BELLA GARDEN RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 361800425
VISIT DATE: 12/05/2020
NARRATIVE
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potential personal rights risk to R1. Based on this information, the allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

This report was reviewed with Administrator, Meza-Brown. A copy of the report and Appeal Rights were provided.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 6