Bella Casa 3

Type of visit: Required - 1 Year

Lcensing Program Analyst (LPA), Toni Nwala made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with administrator, Ursula Carlos. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured at 109.9 F within regulation. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the hallway room. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home and no bodies of water observed. Continued on LIC 809-C LPA began review of client records. three (3) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete LPA began review of employee records- four (4) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification. LPA observed personnel records to be available and complete. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. Medications are centrally stored. There is a locked cabinet in the hallway allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors are a combo unit and are hard wired together, when tested they were found to be operational. Fire extinguisher was serviced on, 03/13/2026. Fire drills are conducted quarterly at the facility with the last drill on 04/17/2026. Based on the information received during this visit today in the areas reviewed, there are no deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, May 14, 2026

Allegation investigated: Staff are isolating resident in care

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Administrator, Ursula Carlos, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and residents, observations, and file review. On May 13, 2025, Community Care Licensing received a complaint alleging that staff was isolating Resident #1 (R1). It was reported that R1 was not permitted to communicate with family and friends via telephone and was confined to their room. It was also reported that R1 stated they felt like a prisoner at the facility. Information obtained from an interview with Administrator stated that facility staff offer a range of activities aimed at keeping residents engaged and physically active. During the interview, Administrator denied any instances of staff isolating residents and stated there were no concerns of any resident feeling isolated or not participating in scheduled activities. Continued on LIC 9099-C. Unfounded Information obtained from interviews with additional staff stated that R1 does actively participate in activities and has not advised of any concerns or issues. However, an interview with R1 revealed they did not feel isolated or neglected by staff. R1 reported no complaints or issues about staff conduct. R1 does not remember stating that they felt like a prisoner at the facility. R1 further stated received a new cell phone, but was having difficulty utilizing it. R1 stated they could place calls independently, but also requested and received staff assistance when needed. Additional interviews with residents confirmed they did not feel isolated or neglected by staff. Residents also reported that staff provide a range of activities, including walking exercises, art sessions, and social engagements. All interviewed residents stated they had not been denied access to phone or mail services while residing at the facility. During an interview with an additional witness, information was advised that there are no concerns with R1 being neglected or isolated. It was stated that R1 actively participates in activities. It was confirmed that R1 received a new phone and there was difficulty working the phone. Additional Witness state there is no concerns with being able to contact R1. Although the facility did not maintain an activities log, a file review was conducted, and case notes indicated that R1 was participating in activities. Based on interviews, research, and record review, the allegation that staff are isolating resident in care is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Administrator Ursula Carlos.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 18-AS-20250513163257

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with administrator, Ursula Carlos. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured within regulation. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the hallway room. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home and no bodies of water observed. LPA began review of client records. six (6) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. Continued on LIC 809-C LPA began review of employee records- four (4) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification. LPA observed personnel records to be available and complete. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. Medications are centrally stored. There is a locked cabinet in the hallway allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors are a combo unit and are hard wired together, when tested they were found to be operational. Fire extinguisher was serviced on, 04/24/2025. Fire drills are conducted quarterly at the facility with the last drill on 04/17/2025. Based on the information received during this visit today in the areas reviewed, there are no deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, May 21, 2025

Type of visit: Required - 1 Year

On today's date 05/24/24 LPA conducted an unannounced 1 year required visit. LPA was greeted and entry by Caregiver Flordeiza Bonilla. The Administrator Ursula Carlos-and Licensee Rommel Carlos arrived shortly after. The facility is licensed to serve age range 60 and over, 6 non-ambulatory, of which 1 may be bedridden. Bedroom #5 (Master) is the designated room for a bedridden resident. The facility also has an approved hospice waiver for 6. There is currently one (1) resident that is receiving hospice services. Below are the observations made during today's inspection: LPA conducted a tour of the interior and exterior of the facility, the facility was observed to be clean, clutter and odor free. The facility is a single story home with 6 bedrooms, 1 of which is for caregiver's, office, 3 bathrooms, laundry room, garage, backyard and kitchen. There is a shaded patio with plenty of space for seating and to promote socialization. All staff present at the facility were observed to have obtained criminal record clearance and were associated to the facility. The emergency disaster drills are being conducted on a quarterly basis and the last drill was conducted on 4/30/24. The smoke and carbon monoxide detectors were tested and were found to be operable. The hot water was tested and found to be within regulatory limits measuring between 109.2-116.2 degrees F. The facility has a mitigation plan on file that was submitted on 3/21/21. There are no known guns or ammunition on the premises, nor are there any pools or bodies of water. The medications are locked inside a cabinet directly outside of bedroom #5. The medications were reviewed and are given according to the physician's instructions. The knives and other sharp objects are stored inside a locked drawer underneath the stove. The chemicals and other hazardous items are locked underneath the kitchen sink and inside a cabinet in the locked laundry room. The facility food supply met the requirement as there was a 2 day supply of perishable and a 7 day supply of non perishable food items observed. There is a refrigerator, and deep freezer in the garage as wel.l that was observed to be fully stocked. LPA conducted a review of all resident files all required documentation was present such as a medical assessment, admission's agreement and appraisal were observed. LPA conducted a review of 3 staff files and observed for the required documentation to be present such as application, and criminal record clearance. However the three of three staff files reviewed revealed that the Cardiopulmonary Resuscitation (CPR) expired on 10/28/23. LPA was informed that the class was taken but there was no proof available for LPA to review during the time of the visit, therefore a citation is being issued. LPA discussed conducting a review of facility personnel roster to ensure all staff are associated to the facility. In addition conducting a review of personnel files to ensure that all necessary documentation is present as well as current such as Identification . Based on today's inspection a citation will be issued on the attached 809D in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report, appeal rights and LIC 9098-Proof of Corrections form was reviewed and provided to Rommel Carlos, Licensee.the state’s words, verbatim · CDSS document, May 24, 2024