374602769-9-25-2023-18-AS-JSRS-CW22MP-20230925173128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602769
Report Date: 09/25/2023
Date Signed: 09/25/2023 05:31:37 PM

Document Has Been Signed on 09/25/2023 05:31 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BELLEVUE VILLA		FACILITY NUMBER:	374602769
ADMINISTRATOR:	CAROLINA S DIZON		FACILITY TYPE:	740
ADDRESS:	2080 HEIGHTS COURT		TELEPHONE:	(760) 518-8508
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	6	CENSUS: 5	DATE:	09/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Carolina Dizon, Administrator		TIME COMPLETED:	05:30 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	Licensed Program Administrator (LPA) Jacqueline Shaw Ross arrived at the facility to conduct a required annual inspection. LPA was granted entry and met with administrator Carolina Dizon. LPA conducted a tour of the facility with Administrator, both inside and outside. At the time of visit, two care providers and 5 residents were present. The facility is a one story five (5) bedroom four (4) bathroom home. One bedroom is shared, two (2) clients to a room and three (3) bedrooms are private. There is one bedroom designated for live-in staff. All indoor and outdoor passageways were free from obstruction. Smoke and carbon monoxide alarms were tested and operable. The temperature inside the facility was 79 degrees. Hot water temperature in client bathrooms was measured at 106.1 degrees F. Each toilet and shower has grab bars for client use and non-skid mats. Client rooms have sufficient lighting and required furnishings. All furniture is in good condition. Emergency drills are being conducted regularly and the last drill was 8/8/23. There is a minimum of one (1) week of nonperishable foods and a minimum of two (2) days of fresh perishable foods. The kitchen is odor free and stocked with appropriate dishes, pots, pans and cups. Sharps and other hazardous items are kept locked and inaccessible to clients. LPA reviewed the kitchen food pantry. The following deficiency was noted: -The kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. LPA noticed an infestation of flying insects inhabited the walk in food pantry. Upon further inspection, insects were seen inside food boxes, and on shelves. Continued on LIC809C...

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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 4

Document Has Been Signed on 09/25/2023 05:31 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLEVUE VILLA	FACILITY NUMBER: 374602769
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in [one] out of [one] objects and identifiers which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Administrator will remove all of the food items inside the pantry, spray with insect spray, air out pantry, clean pantry and provide photos of proof of correction by POC date.

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Administrator will review and update MAR and all client medication to ensure accuracy. Administrator will provide a refresher training to staff and submit proof of training completed to the Department by 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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 09/25/2023 05:31 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLEVUE VILLA	FACILITY NUMBER: 374602769
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Administrator will provide a refresher to staff who administer medication and provide proof of training to the Department by the POC 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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLEVUE VILLA	FACILITY NUMBER: 374602769
	VISIT DATE: 09/25/2023

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
26
27
28
29
30
31
32

Staff records were reviewed and indicated staff is properly associated to the facility. Review of client records indicates in each of their files, there is a Medical Assessment, needs and services plan and appraisal and a signed, dated Admission Agreement.

Medication was observed to be centrally stored and secured in a locked cabinet. The following deficiencies were observed upon review of how medications are stored and recorded (MAR):

-Medications for all clients were prepared in advance for the evening distribution and stored in medication cups.

-Medication record (MAR) showed staff signed for medication, before medication was to be dispensed five (5) days in advance.

Deficiencies were noted and are cited in accordance with California Code of Regulations, Title 22 Division 6 on the attached 809-D forms.

An exit interview was conducted, plans of correction (POCs) and appeal rights were reviewed, and a copy of this report along with licensee rights was provided to Administrator Carolina Dizon.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4