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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603756
Report Date: 09/10/2024
Date Signed: 09/11/2024 07:40:31 AM

Document Has Been Signed on 09/11/2024 07:40 AM - 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BELLAS FACILITYFACILITY NUMBER:
374603756
ADMINISTRATOR/
DIRECTOR:		CASTRO, JONATHANFACILITY TYPE:
735
ADDRESS:2024 HIDDEN MESA ROADTELEPHONE:
(619) 328-2291
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 4CENSUS: 4DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Direct Support Professional Hector GuevaraTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Direct Support Professional (DSP) Hector Guevara. According to the facility’s license, the facility has a maximum capacity of four (4) clients of whom all must be ambulatory.

LPA toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

Cooking/dining equipment and utensils were present. Medications were labeled, as required, and stored in locked areas. Water temperature was measured at 108 degrees F, ambient room temperature was 75 degrees F.



A fully enclosed and locked pool is present. Per DSP, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible.

Client records reviewed contained the required documentation. Staff records reviewed did not contain health screening, tuberculosis test results, or First Aid certificate for Staff 1. There were no sharp objects or toxic chemicals accessible to clients. Staff and client responses to interviews did not reveal any concerns.



LPA Strong attempted to contact Administrator via telephone with no answer. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-Ds). An exit interview was conducted with DSP Hector Guevara, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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 09/11/2024 07:40 AM - It Cannot Be Edited


Created By: Iby Strong On 09/10/2024 at 02:15 PM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELLAS FACILITY
FACILITY NUMBER: 374603756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on records reviewed, the licensee did not comply with the section cited above in 1 out of 2 staff which poses a potential health risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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3
4
Licensee agrees to provide proof of health screening for staff 1 by plan of correction date via email to LPA.
Type B
Section Cited
CCR
80066(a)(11)
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: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records reviewed, the licensee did not comply with the section cited above in 1 out of 2 staff which poses a potential health risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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4
Licensee agrees to provide proof of tb screening for staff 1 by plan of correction date via email to LPA.
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:Simon Jacob
LICENSING EVALUATOR NAME:Iby Strong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/11/2024 07:40 AM - It Cannot Be Edited


Created By: Iby Strong On 09/10/2024 at 02:15 PM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELLAS FACILITY
FACILITY NUMBER: 374603756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records reviewed and interview the licensee did not comply with the section cited above in 1 of 2 staff which poses a potential health and safety risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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2
3
4
Licensee will provide proof of First Aid training for Staff 1 by due date via email.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Simon Jacob
LICENSING EVALUATOR NAME:Iby Strong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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