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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604475
Report Date: 07/19/2022
Date Signed: 07/19/2022 12:48:17 PM


Document Has Been Signed on 07/19/2022 12:48 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
RIVERSIDE, CA 92507



FACILITY NAME:VILLA BERNARDOFACILITY NUMBER:
374604475
ADMINISTRATOR:ANDERSON-CARTER, DAWNFACILITY TYPE:
740
ADDRESS:2960 BERNARDO AVE.TELEPHONE:
(858) 209-6618
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:10CENSUS: 8DATE:
07/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Yessenia Rebolledo - Facility Director/AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin was at the facility conducting an investigation on a complaint (#18-AS-20220711091001) when LPA Colvin observed the following items which were addressed:
  • Reporting Requirements - LPA Colvin observed that no incident report (SIR) has been submitted to Licensing in regards to prior resident's (R1's) behavior leading up to R1's psychiatric hospitalization, nor R1's psychiatric hospitalization, which required law enforcement accompaniment. Deficiency cited.

  • Eviction Procedures - On 7/2/22. R1 and R1's representative were provided with a 90-day eviction notice which listed the reason for R1 being evicted as the facility unable to meet R1's needs. The facility failed to do a reassessment of R1 prior to issuing the eviction notice, as required by Title 22 Regulations (if this is the basis of the eviction). Deficiency cited. Additionally, the facility failed to provide Licensing with a copy of the eviction notice. Deficiency cited.

  • Acceptance and Retention Limitations - LPA Colvin observed that the facility is licensed for caring for elderly persons over the age of 60, and advertises Dementia Care. The facility accepted and retained R1, who is under the age of 60 and has a primary diagnosis of mental health (Schizophrenia). The facility accepted and retained R1 until R1's mental health behaviors became too much for staff to handle, and according to the Administrator, caused the other residents distress. Deficiency cited.

  • Maintenance and Operation - Upon LPA Colvin's arrival to the facility, LPA Colvin observed four full garbage bags right outside the facility by the front doors. LPA Colvin will be issuing a Technical Assistance (TA) Note instead of a deficiency as the garbage backs were picked up and disposed of soon after LPA Colvin's arrival.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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


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
RIVERSIDE, CA 92507
FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 374604475
VISIT DATE: 07/19/2022
NARRATIVE
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  • Maintenance and Operation (Con't) - LPA Colvin observed two glue traps for insects near the kitchen and the dining room table, both of which contained a large amount (over 12) dead insects such as spiders and pill bugs. LPA Colvin will be issuing a TA Note instead of a deficiency as this is a relatively safe means of pest control (instead of poison which residents could ingest), but should be disposed of regularly in order to maintain the facility in sanitary condition.


Based on LPA Colvin's investigation, the facility was cited and deficiencies noted on LIC809Ds. LPA Colvin conducted an exit interview with Administrator Yessenia Rebolledo where a copy of this report, LIC 809Ds, LIC9102 TA Violations, and appeal rights were provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/19/2022 12:48 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
RIVERSIDE, CA 92507


FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 374604475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2022
Section Cited

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Acceptance and Retention Limitations: (c) No resident shall be accepted or retained if any of the following apply: (3) The resident's primary need for care and supervision results from either: (A) An ongoing behavior, caused by a mental disorder, that would upset the general resident group;... This was not met by:
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Based on record review and interview, the Licensee did not comply with the above regulation with at least one resident. R1 was admitted to the facility with a primary diagnosis of Schizophrenia, whereas the facility specializes in Dementia care. This was an immediate personal rights risk to residents.
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Plan of Correction date of 7/20/22.
Type A
07/20/2022
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish...reports...including...: (1) A written report shall be submitted...within seven days of the occurrence of any of the events specified ...(D) Any incident which threatens the welfare, safety or health of any resident,... This requirement was not met by:
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Based on record review, the Licensee did not comply with the above regulation with at least one occurrance. LPA Colvin observed that no Incident Report was submitted to Licensing for the date of 7/4/22 in which R1 was put on a 51/50 due to danger to others. This was an immediate safety risk to residents in care.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/19/2022 12:48 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
RIVERSIDE, CA 92507


FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 374604475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2022
Section Cited

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Eviction Procedures: (a) The licensee may evict a resident for one or more of the reasons listed...(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463.... This requirement was not met by:
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Based on record review, the Licensee did not comply with the above requirement with at least one resident. LPA Colvin observed that R1 was not given a reassessment to confirm that the facility could no longer meet R1's needs. This was an immediate personal rights violation of R1.
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Type B
07/29/2022
Section Cited

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Eviction Procedures: (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by:
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Based on record review, the Licensee did not comply with the above regulation with at least one resident. LPA Colvin obseved that the eviction notice provided to R1 on 7/2/22 was never provided to Community Care Licensing. This was a potential personal rights risk of R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4