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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800425
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:49:42 PM


Document Has Been Signed on 01/19/2024 03:49 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:BELLA GARDEN RESIDENTIAL SENIOR CAREFACILITY NUMBER:
361800425
ADMINISTRATOR:MEZA-BROWN, ELIZABETHFACILITY TYPE:
740
ADDRESS:22790 VAN BUREN STREETTELEPHONE:
(909) 695-8597
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:6CENSUS: 5DATE:
01/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Elizabeth Colunga, LicenseeTIME COMPLETED:
03:52 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to return facility records and discuss issues found during LPA's review of records. LPA met with licensee Elizabeth Colunga who was informed of the reason for the visit.

On 01/12/2024, LPA conducted an unannounced required annual visit for this facility however no staff or resident records were available for review. As part of the correction plan and, as agreed upon by Licensee and LPA, Licensee brought facility records to the Regional Office on 01/16/2024 for LPA Bueno to review. LPA has returned all staff and resident records to the facility during this visit. All deficiencies cited on 01/12/2024 has been satisfied.
Letters for cleared proof of correction were issued during today's visit.

Personnel records review: LPA reviewed employee records for fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, including Dementia care. LPA confirmed that administrator certification is current but awaiting verification from the Department.
Resident records review: LPA reviewed resident files and found current medical assessments and TB test results, necessary consent forms, identification and emergency information, appraisal needs and service plans, admission agreement, and personal rights notification. LPA found that Resident 1 (R1) is diagnosed with Dementia. This facility does not have an approved Dementia care plan. This poses a potential health and safety risk to residents in care. Refer to LIC 809D for deficiency cited.

An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to licensee Elizabeth Colunga
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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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Document Has Been Signed on 01/19/2024 03:49 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: BELLA GARDEN RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 361800425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
87705(c)(1)

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills.
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Licensee shall submit an exception request for R1 to include regulation complaince and state that Dementia care will not be advertised by this facility. Otherwise, Licensee will need to remove R1 from the facility.
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This requirement was not met as evidenced by:
Based on records review, Resident 1 (R1) has a Dementia diagnosis when the facility does not have an approved Dementia care plan. This poses a potential health and safety risk to residents in care.
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If Licensee chooses to admit new residents with Dementia, Licensee shall submit a new operation plan to include Dementia Care.

Proof shall be submitted to the Department no later end of POC date.

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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
LIC809 (FAS) - (06/04)
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