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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800425
Report Date: 01/12/2024
Date Signed: 01/12/2024 04:05:27 PM


Document Has Been Signed on 01/12/2024 04:05 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:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Elizabeth Meza-BrownTIME COMPLETED:
04:07 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted by staff who was informed of the purpose of the visit. Staff notified Licensee of LPAs arrival and Licensee arrived during the visit. LPA toured the interior and exterior of the home with staff and then with Licensee.

Physical Plant and Operational Requirements: LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature was measured and Licensee made corrections during today's visit to ensure compliance. Cleaning supplies and hygiene provisions are kept locked and secured. Fire extinguishers were observed to be charged and last inspected on 01/10/2023. LPA tested carbon monoxide detectors while Licensee tested interconnected smoke alarms and all were found in working order. All outdoor and indoor passageways and ramps are free of obstruction. A locked area is provided for medications and sharp objects. There is a working telephone at this location. The LIC 610E and emergency client files are maintained. Licensee presented current plan of operation and admission agreement. LPA observed Resident rights, house rules, and complaint posters and grievance procedures are posted in the facility.

Resident Files, Personnel Files/Training, and Medication Records: LPA reviewed centrally stored medication list and all scheduled and PRN medication and found that they were administered as prescribed.
Neither resident nor staff records were unavailable for review during today's inspection. This poses a potential health and safety concern for residents in care. All records shall brought into the Regional Office no later than end of business of correction date for LPA Bueno to review.
Food Service: LPA was present during lunch time. The meal is adequate to meet the nutritional needs of the residents. Kitchen and dining areas were kept clean and organized. Food supply meets the requirement of 7 day supply of nonperishable and 2-day supply of perishables food items.

Refer to LIC 809D for cited deficiencies and technical violations for issues related to deficiencies. An exit interview was conducted where this report, LIC 809D, LIC9102A, and appeal rights were discussed and copies provided to Licensee. Additional technical notes were provided electronically to Licensee.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 01/12/2024 04:05 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: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and Licensee interview, the licensee did not comply with the section cited above as no resident records were available for review during today's visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2024
Plan of Correction
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All resident records will be placed at the facility and will be available for licensing review. Proof of correction shall be submitted to the Department no later than end of POC date.
Type A
Section Cited
CCR
87412(g)
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and Licensee interview, the licensee did not comply with the section cited above as no staff files or training records were available for review during today's visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2024
Plan of Correction
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All personnel records will be placed at the facility and will be available for licensing review. Proof of correction shall be submitted to the Department no later than end of POC 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/12/2024 04:05 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: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and Licensee interview, the licensee did not comply with the section cited above as Licensee/Administrator records were not available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Licensee shall maintain full personnel record as an employee should Licensee provide care and supervision to residents in care. Proof of correction shall be submitted to the Department no later than end of POC date.
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee interview and records review, the licensee did not comply with the section cited above as staff on duty (S1) had a background clearance but was not associated to the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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 Licensee shall associate S1 to the facility. Proof of correction shall be submitted to the Department no later than end of POC 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3