Bella Nova Villa II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct the required annual visit today. Upon arrival, the LPA was greeted by Administrator, Maria Ayala and the reason for the visit was explained. Entrance interview conducted. Beginning at 10:15 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: Common Areas: The living room and dining room area furniture was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed a fireplace in the living room; adequately covered. The LPA observed several new fire extinguishers throughout the facility with a purchase date of 07/11/2026. Required postings were observed throughout the common space. There is a working telephone on premises. Cameras were observed in the common areas. No hazards/obstructions observed inside or out. Bedrooms: There are six (6) bedrooms for resident use. All bedrooms are designated private / single occupancy. Bedrooms #1, #2, and #4 have direct access to outside. Bedrooms were observed to be furnished appropriately and had sufficient lighting. There are additional clean linens, blankets, and towels in a closet by the main hallway. Report Continued on LIC 809C... Report Continued from LIC 809... Restrooms: There are two (2) restrooms for resident use. Bathrooms were clean and sanitary, and fixtures were in operating condition. Showers had non-skid surfaces and grab bars. The bathrooms were sufficiently stocked with soap and paper towels. Starting at 10:26 a.m., the hot water temperature was measured in resident bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit at the time of the visit. Garage: The garage has direct access to the house and was locked at the time of the visit. A sufficient supply of emergency food and water was observed. Detergents and cleaning supplies were observed locked and inaccessible at the time of the visit. Laundry Room: Washer and dryer were observed in the laundry room. Staff take care of all residents laundry needs. Backyard: The backyard has a shaded area with adequate furniture for resident use. Emergency passageway was observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms for emergency purposes. The LPA observed a locked shed for storing purposes at the time of the visit. No bodies of water noted at the time of the visit. Kitchen: The LPA inspected the kitchen/food service area at approximately 10:35 a.m. Knives and sharps were observed locked and inaccessible at the time of the visit. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Dates were observed clearly marked on items at the time of the visit. Records: Record review began at approximately 10:45 a.m. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent for treatment form, preplacement appraisals, appraisals, and current needs and services plan. All files were in order. Report Continued on LIC 809C... Report Continued from LIC 809C... Six (6) personnel files including the current Administrator’s file were reviewed for, but not limited to: personnel record, health assessment with negative TB test results, criminal record clearance, first aid/CPR training, and the appropriate yearly training. All personnel files were complete. Medications: The LPA conducted a medication review at approximately 01:30 p.m. Medications are centrally stored and kept in a locked closet by the main hallway. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appear to be administered as prescribed at the time of the visit. Emergency Disaster Plan: During today’s visit, the LPA reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 08/13/2026. No citations issued at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 3, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10:46AM. The LPA met with the Licensee Maria Ayala and informed them of the reason for the visit. Entrance interview conducted. Beginning at 11:14AM, the LPA and Licensee toured the physical plant areas inside and outside to ensure there were no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. COMMON AREAS: There was a locked laundry room that connected to the kitchen. The laundry machines were in good condition and had locked cabinets that contained general supplies. There was a garage that remained secure and contained emergency food and water, files, cleaning supplies, and a refrigerator/freezer with extra food. At the time of the visit, the living room and dining room furniture were observed to be in good condition. The living room had a fireplace that was inoperable and screened. Required postings were observed in the entryway walls. A locked hallway closet contained kitchen knives and medications. The facility maintained a comfortable temperature throughout the visit. Nightlights were observed throughout the facility. Report Continued on LIC 809-C BEDROOMS/RESTROOMS: There were six (6) total bedrooms, each private. Bedrooms #1, #3, and #5 had a direct exit to the outside and Bedroom #3 was approved for one (1) Bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the hallway closet. There were three (3) total restrooms in the facility: two (2) shared restrooms and one (1) private resident restroom. Restrooms were clean, sanitary, and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured at 116.4 degrees F, which is within the required range per regulation. OUTDOOR AREA: The surrounding grounds had a shaded patio area equipped with furniture in good condition for residents and visitor use. The rear also had outdoor activities for resident use. There was one (1) shed that remained locked and contained general storage. There were two (2) emergency exits located on the sides of the facility that were self-latching. All exits and passageways were free of obstruction. RECORDS: Record review began at 11:51AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 09/05/2025. Smoke and carbon monoxide detectors were tested at 1:01PM and were operational. Fire extinguishers were observed and were purchased on 08/01/2025. Report Continued on LIC 809-C MEDICATIONS: Medication review began at 2:00PM. Medications were centrally stored and kept inaccessible. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Sep 22, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cortez conducted a Case Management - Deficiencies visit. The purpose of the visit is to issue citations for deficiencies observed during a case management incident visit not related to the incident. During the visit on 05/29/2025, the LPA observed surveillance cameras in common areas. The LPA inquired about video footage from 05/16/25. The Administrator allowed the LPA to observed several video clips from 05/16/25, the LPA observed that by selecting the speaker button all videos had audio. Upon observation, the Administrator stated that they were unaware the cameras had audio component. During the visit the Administrator disconnected the cameras. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 6, 2025

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on observation the Licensee did not comply with the section cited above in that cameras in the common areas have an audio component which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: The Administrator unplug the cameras during today's visit, and cameras will remain disconected until they can confirm that the cameras do not record audio and will submit a statement detailing if cameras have or do not have an audio system. by 06/06/25.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit at 12:30 p.m. The LPA met with staff and explained the reason for the visit. Entrance interview conducted. Administrator Maria Ayala arrived shortly thereafter. The Department received a self reported incident report regarding Resident #1 (R1) on 05/21/2025. During today’s visit, the LPA conducted a physical plant tour to ensure there are no immediate health and safety concerns, conducted an in-person interview with the Administrator, R1, a file review for R1, observed several video footage (clips) from 05/16/25, and obtained copies of pertinent documents relevant to the incident. If further investigation is needed an LPA will return at a later date. No immediate health and safety concerns were observed during the visit. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, May 29, 2025

Allegation investigated: Staff does not properly discard deceased residents medication.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival, LPA met with Administrator Maria Ayala and explained the reason for the visit. On 09/06/24, between 10:15 a.m. and 5:30 p.m., the LPA conducted a tour of the facility, conducted a file review and a medication audit. During today's visit the LPA conducted three (3) staff interviews, three (3) interviews with residents family members and a medication audit. Report will continue on LIC9099-C (2nd Page). Substantiated On the allegation "Staff does not refill residents medication in a timely manner"; it is the concern of the reporting party that Staff #1 does not refill the residents medication in a timely manner. To investigate the allegation the LPA conducted a medication audit for four (4) out six (6) residents, observations and interviews. During the medication audits the LPA observed all prescribed medications to be filled, and the administrator informed the LPA that a refill had already been submitted for the medications with low quantities, such as a resident #2's (R2's) Haloperidol. During today's visit the LPA observed R2's Haloperidol medication being delivered. Staff interviews revealed that when the residents have about 10 days left on medications they will notify the administrator, so the administrator can get the medications refilled, and that the resident have not gone without medications due to them not being refilled in a timely manner. Staff interviews also revealed that a Hospice nurse comes twice a week and they let the nurse know every time a resident needs a refill. The Administrator stated that they have never run out of medications, and that if they are ever very low on any medication they would place a STAT order with the hospice nurse or resident's physician and get a same day order delivered. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time. On the allegation "Staff mismanaged residents medication"; it is the concern of the reporting party that Staff #1 (S1) administers medication (Lorazepam and Haloperidol) to residents that are not prescribed to them. It was further reported that if a resident is feeling agitated and S1 does not have the medication prescribed to them, S1 would use another residents medication. To investigate the allegation the LPA conducted observations, medication audit, and interviews. On 09/06/24, when a resident was agitated the LPA observed staff provide medication to the resident. The LPA verified that it was the resident's prescribed medication, and correct time to provide. Medication audit conducted on 09/14/24 revealed that only two (2) residents take lorazepam, one (1) resident takes haloperidol. The medication was centrally stored and documented on the Centrally Stored Medication and Destruction Record (CSMDR) and there was nothing observed to suggest that their medications are being provided to other residents. Staff interviews revealed that they have never seen S1 administer medications to residents that are not prescribed to them. In addtion, S1 denied ever giving residents medications that were not prescribed to them. Furthermore, interviews with residents family members revealed that they have no concerns regarding the residents medications. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time. Report will continue on LIC9099-C (3rd page). On the allegation "Staff does not ensure that an adequate food supply is maintained on premises"; it is the concern of the reporting party that 2-3 weeks have gone by where there is no groceries or wipes for residents. It was further reported that staff members would purchase or sometimes order take out and that the residents complain they’re hungry. To investigate the allegation the LPA conducted a plant tour and interviews. On 09/06/24 and during today's visit, the LPA observed a sufficient amount of perishable and non-perishable food at the facility. The LPA also observed that snacks such as fruit and beverages were available for the residents. When the LPA arrived during today's visit the LPA observed three (3) residents at the kitchen table that had just finished eating breakfast. The LPA observed staff asking the the residents if they wanted any additional food, and provided cookies. In addition, during today's visit, the LPA observed staff cook and provide a squash side dish, paired with a macaroni and corn salad, and a taco from taco bell for lunch. Staff encouraged the residents to eat, and continue to offer other options. Staff interviews revealed that they always have food at the facility and the residents are not left hungry. If there are ever running low on supplies staff will notify the administrator, and they provide a list of things that are needed to the administrator every Monday and Friday. The administrator stated that the residents are never left hungry, and they are provided a variety of food. They went on to state that they order take out once a week, usually on Saturday's for lunch to give the resident's more variety in their food, but always pair it with vegetables and fruits to make it a balanced meal. Furthermore, all interviews conducted with residents family members revealed that they visit the residents once a week, and they have no concerns with the care being provided by the staff, and are very satisfy with the care provided including the meals. One of the family members revealed that they are pleased that the residents get fresh food, and have no concerns residents are being left hungry Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and provided. On the allegation "Staff does not properly discard deceased residents medication."; it is the concern of the reporting party that when residents pass away staff #1 (S1) would not properly discard the medication and saves the medication in boxes. To investigate the allegation the LPA conducted a medication audit on 09/06/24. During the medication audit, the LPA observed four (4) different medications that were prescribed to a resident (R1) that had passed away on 08/07/2024 stored in a locked night-stand in the garage. The medication was among other extra medications for current residents, that had not been administered or discontinued. Upon observation, S1 stated that they were not aware that the medication for R1 was there and did not know what to do with the medication. Based on observation the allegation that Staff does not properly discard deceased residents medication is Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).Exit interview conducted. Today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Sep 14, 2024 · control 29-AS-20240829160224

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Sep 17, 2024

87465(i) Prescription medications which are not taken with the resident upon termination of services,not returned to the issuing pharmacy, ...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident... This requirement is not met as evidenced by: Based on observations, interview, the licensee did not comply with the section cited above by not disposing or returning to issuing pharmacy Resident's medication who passed away, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2024

Plan of correction: Administrator agress that by 09/17/24 they will submit a statement of understanding that they reviewed the regulation and confirm medications awaiting destruction have been destroyed.

Type of visit: Required - 1 Year

At 10:15 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and a resident's family member and informed them of the reason for the visit. Administrator Maria Ayala arrived approximately at 11:00 a.m . When the LPA arrived they observed staff #1 and a resident's family member (F1), who is not finger-printed cleared at the dining table going through resident medication records. F1 proceeded to put all files away in the hallway closet where the files and resident medications are stored. At 10:20 a.m. the LPA conducted a tour of the physical plant with staff to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms, two (2) resident restrooms, and one (1) staff restroom. The LPA observed fire extinguishers which were fully charged and last purchased in July 2024. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Snacks and beverages are always available for the residents. Knives are stored in a locked closet, and cleaning supplies are stored in locked cabinet, and in the locked garage. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding. Starting at 10:30 a.m.,the LPA observed the auditory alarms in the exist doors of rooms #1, #3 and #6 to not be operable. At 10:32 a.m. the LPA observed the exit door in room #3 blocked with an arm chair. At 10:39 a.m. the LPA observed the exit door in room #6 blocked with a walker, and chairs. Upon observation, staff removed items from the exit doors. Report will continue on LIC809-C. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 11:40 a.m. water temperature in resident’s restroom in room #6 was measured at 135.3 degrees Fahrenheit. At 11:43 a.m. water temperature in the common restroom was measured at 135.5 degrees Fahrenheit. At 11:48 a.m. the water temperature in the kitchen measured at 136.6 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the first living room, which is covered with a screen. At 10:33 a.m. the LPA observed the light in the hallway leading to the common restroom inoperable. The garage: The LPA observed the garage where additional supplies and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in the garage. The garage is locked. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. The LPA observed the outdoor furniture with spider webs and dust. Record Review: At 12:38 p.m. a review of facility files was initiated. The LPA reviewed four (4) out of seven (7) staff files. The following was observed: Administrator's file was missing, and all staff records reviewed did not have the required annual training, and three staff did not have a current 1st aid/CPR certificate. In addition Staff #2 (S2) had a Health screening (LIC503) that belong to another staff with their name white-out and S2's name written over. Upon observation the Administrator stated that about a month ago certain staff and residents files had been stolen or altered by previous employees who no longer work at the facility. However the incident was never reported to CCL. The LPA reviewed five (5) out of six (6) resident files. The following was observed: One out five residents did not have TB results on file, otherwise all files were complete. Report will continue on LIC809-C (3rd page). Medication Audit: At 3:20 p.m. a medication audit for two (2) residents was initiated. The following was observed: The medications were stored in a locked closet which is locked and inaccessible to the clients. During Resident #1 (R#1's) audit, the LPA observed the quantity for all medications not documented on the Centrally Stored Medication and Destruction Record (CSMDR) and Bupropion medication not recorded at all. In addition, according to the start date on the CSMDR, and the quantity on the medications prescription label R1's Levothyrozine Sodium 25mcg should have seventeen (17) tablets on the bubble pack, however the LPA observed twenty-three (23) tablets on the bubble pack. During R#2’s audit, the LPA observed an excessive amount of extra medications stored in the garage, which the administrator stated they did not know what to do with as they were extra medications. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit inter view conducted and copy of the report and appeal rights provided to Administrator Karina Rosales Antig.the state’s words, verbatim · CDSS document, Sep 6, 2024