361800425-1-22-2025-56-AS-ESEO-DD6RSA-20250122121624

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800425
Report Date: 01/22/2025
Date Signed: 01/22/2025 12:16:57 PM

Document Has Been Signed on 01/22/2025 12:16 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BELLA GARDEN RESIDENTIAL SENIOR CARE		FACILITY NUMBER:	361800425
ADMINISTRATOR/ DIRECTOR:	MEZA-BROWN, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	22790 VAN BUREN STREET		TELEPHONE:	(909) 695-8597
CITY:	GRAND TERRACE	STATE: CA	ZIP CODE:	92313
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:	Ana Delgado Caregiver		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/22/2025 at 08:35 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA Serrano met with caregiver Ana Delgado and was granted entry to the facility. Caregiver Ana called the administrator and administrator had a court appointment and not able to come to the facility. At the time of the visit there was two (2) staff present, and five (5) residents present. The facility is a three (3) bedrooms, two (2) bathrooms home with a kitchen/dining area, living room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory and two (2) hospice care resident and the current census is six (6) residents. LPA Serrano was accompanied by Caregiver Ana to conduct a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPA Serrano inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA Serrano measured and observed the water temperatures in the bathroom to be at 118 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, and the disaster plan were posted in a common area. LPA observed that the facility did not have the Infection Control Plan available for review at the time of inspection. Deficiency will be issued. *Continuation in LIC809C *

Karen Clemons	TELEPHONE: (951) 836-2784
Eldin Serrano	TELEPHONE: 951-248-0351
	DATE: 01/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA GARDEN RESIDENTIAL SENIOR CARE	FACILITY NUMBER: 361800425
	VISIT DATE: 01/22/2025

NARRATIVE

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Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medication Closet with the resident’s medications locked. LPA Serrano observed complete first aid kit at the facility.

Food Service: Seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Serrano reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Serrano observed resident files reviewed were complete. LPA Serrano reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications/Medication Administration Record (MAR) were audited and in compliance.

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, and Appeal Rights was discussed and provided to Ana Delgado.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/22/2025 12:16 PM - It Cannot Be Edited

Created By: Eldin Serrano On 01/22/2025 at 11:51 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(a)

Infection Control Requirements

(a) A licensee shall ensure that infection control practices are maintained as follows: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above by not ensuring that the facility have the Infection Control Plan available for review at the time of inspection which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2025
	Plan of Correction
1 2 3 4	LIcensee stated that the facility will submit a copy of the Infection Control Plan on the plan of correction (POC) due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Karen Clemons

TELEPHONE: (951) 836-2784

LICENSING EVALUATOR NAME:

Eldin Serrano

TELEPHONE: 951-248-0351

LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3