Bellahomecare I

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified himself and discussed the purpose of the visit with Licensee Cherry Cook. According to the facility’s license, the facility is approved to serve six (6) residents. Five (5) residents may be non-ambulatory and one (1) resident may be bedridden. LPA, accompanied by Licensee 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. Both the facility’s ambient internal temperature and hot water temperature were at compliant readings. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. Per Licensee, 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. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. LPA file review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Licensee Cherry Cook to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Mar 4, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified himself and discussed the purpose of the visit with Licensee Cherry Cook. According to the facility’s license, the facility is approved to serve six (6) residents. Five (5) residents may be non-ambulatory and one (1) resident may be bedridden. LPA, accompanied by Licensee 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. Both the facility’s ambient internal temperature and hot water temperature were at compliant readings. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. Per Licensee, 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. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. LPA file review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Licensee Cherry Cook to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Mar 5, 2025

Allegation investigated: Facility was not kept free of pests Facility was not kept clean

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to open a complaint investigation. While at the facility LPA investigated and delivered findings regarding the above-mentioned allegations. LPA identified himself and was granted entry by Caregiver Marcela Torno. LPA stated the purpose of the visit with Caregiver and once again stated the purpose of the visit and reviewed the findings of the complaint with Licensee Cherry Cook who arrived at the facility a short while after. The Department’s investigation consisted of interviews with staff, residents, review of pertinent records, and LPA observations of the facility grounds, including; resident rooms, bathrooms, common areas, kitchen,garage and outside area. It was alleged that the facility was not kept free of pests. It was reported that cockroaches were found under a resident's blanket. It was also alleged that the facility was not kept clean. It was reported that trash was not being taken out and the resident rooms and bathrooms were dirty. (Continued on LIC9099-C) Unsubstantiated LPA Interviewed Resident 1 (R1) who stated that they have lived at the facility since May 2024 . R1 stated that they have never seen cockroaches in their room or the facility. R1 further stated that they have never seen cockroaches in their bed. R1 stated that R1 as well as several other residents keep food items in their room and the facility staff regularly advises them to "be careful with food in the rooms" since it can attract pests. LPA interviewed Resident 2 (R2) who stated that they have lived at the facility since May 2024. R2 stated that R2 has never seen any cockroaches in their room, on their bed or in the facility. R2 stated that they have not witnessed trash piled up in the facility or a dirty bathroom. LPA interviewed Staff 1 (S1) who stated that they have worked at the facility since March 2024. S1 stated that S1 works at the facility three days a week. S1 stated that staff take out the trash every day. S1 stated that most of the resident rooms are cleaned and mopped every other day, with the exception of two resident rooms that are mopped daily due to regular "messes that are made." S1 stated that S1 has never seen any cockroaches in the resident rooms, beds or the facility. S1 stated that a few residents keep food in their rooms and the staff periodically check rooms for spills or trash that needs to be cleaned up. LPA interviewed Licensee who stated that the facility is cleaned daily including resident rooms and bathrooms. Licensee stated that the facility trash is thrown out every day and the trash "pick up" is weekly. Licensee stated that although the facility has never had any cockroaches, the facility did have a brief issue with "black ants" last year due to food storage in a specific residents room. Licensee stated that the ants were treated and the resident was advised that their food would be stored in the kitchen to avoid ant infestations. On February 18, 2025, LPA toured the facility. LPA thoroughly inspected each of the resident’s rooms (under blankets, under beds, closets, drawers), bathrooms, dining room, living room, family room, garage, backyard and both sides of the facility. LPA did not find any cockroaches either dead or alive. LPA found all of the trash cans in the facility were emptied out including the trash cans in the kitchen, bathrooms and resident rooms. LPA found all of the resident rooms and bathrooms to be clean with no foul odors. LPA found the facility overall to be clean and sanitary. (Continued on LIC9099-C) Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during interviews, records review, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Licensee Cherry Cook. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Cherry Cook at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Feb 18, 2025 · control 08-AS-20250211162354

Allegation investigated: Licensee did not offer resident social interaction.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Marisela Torno. LPA also spoke with Adminisrator Cherry Cook via phone. The Complainant alleged that Licensee did not offer Resident #1 (R1) social interaction. CCLD’s investigation involved unannounced facility tours, review of pertinent care records and activities schedule, and interviews of pertinent facility staff, residents, and outside sources. Licensee possessed a sample schedule of activities. Staff interviews generally showed: In practice, staff modified/adjusted the offerings as as needed to fit the abilties and interests of the residents in care. Some of the residents had lengthly outside commitments, such as attending day program or dialysis treatment, several days per week. [CONTINUED ON LIC 9099-C] Unsubstantiated [CONTINUED FROM LIC 9099] Resident interview showed: Residents had freedom in choosing their activities, staff socialized with them, and they had enough activities to keep them entertained when they were at the facility. According to care records, and corroborated by staff and outside source interviews: During the timeframe of the allegation, R1 was diagnosed with “Dementia,” “Senlie Degeneration of the Brain,” “CVA residual hemiplegia,” and “left elbow amputation,” among other conditions. R1 was concurrently under the care of a visiting hospice agency for end-of-life care. R1 spent their days in bed, and was not physically capable of partaking in activities outside of their bedroom with their housemates. By the date the Department received the complaint, R1 had already moved out of the facility. However, during a prior site visit on 05/02/2024, LPA had observed facility staff visit with R1 bedside, treating them with kindness. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not offer R1 social interaction. The allegation is therefore Unsubstantiated, and no deficiency was cited. An exit interview was conducted with Cook. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to the Licensee during today’s visit.the state’s words, verbatim · CDSS document, Sep 23, 2024 · control 08-AS-20240731112008

Allegation investigated: -Licensee involuntary transferred/discharged a resident. -Licensee did not serve resident the required eviction notice.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Lide Cerna. LPA also spoke with Adminisrator Cherry Cook via phone. The Complainant alleged that Licensee involuntarily transferred/discharged Resident #1 (R1) from the facility. They also alleged that Licensee did not serve R1 or their responsible person (RP) with the required eviction notice. CCLD’s investigation involved an unannounced facility tour, review of pertinent care and administrive records, and interviews of pertinent facility staff and outside sources. [CONTINUED ON LIC 9099-C] Substantiated [CONTINUED FROM LIC 9099] Interviews and records aligned to show: At the time R1 moved into the facility on 02-01-2023, RP signed R1’s Admissions Agreement with the facility, as their responsible person. R1’s doctor had diagnosed R1 with Dementia, determined they were confused/disoriented, and wrote that R1 was both bedridden and paralyzed on the left side of their body due to a prior cerebral infarction. In the few months leading up to the date of their move out, R1’s incurred a partial rent balance with the facility that was past due, and attempts to resolve the balance hit a dead end. Licensee leveraged R1’s hospice agency to find alternate housing for R1 and to arrange R1’s transport there. On 06-04-2024, without RP’s consent (and R1 was not capable of consenting), R1 was physically moved out of Bellahomecare I to another care facility. While Licensee may have had a valid reason to evict on the basis of “nonpayment of the rate for basic services within ten days of the due date,” they did not serve R1 or their RP with the required 30-day written eviction notice. Based on records and interviews, a preponderance of evidence exists to show that Licensee involuntary transferred/discharged R1 from the facility and that Licnesee did not serve R1 or their RP with the required 30-day eviction notice described in regulation. Both allegations are therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Cook via phone. A copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today’s visit.the state’s words, verbatim · CDSS document, Aug 1, 2024 · control 08-AS-20240731112008

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Aug 1, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions.” This requirement was not met, as evidencd by: Based on records review and interviews, Licensee did not ensure that 1 of 6 residents (R1) was protected from involuntary transfer, discharge, and/or eviction. This posed an immediate personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: Per interview of R1’s RP, they do not desire/intend for R1 to return to the facility; this resolves the immediate risk. Licensee also agreed to retrain all current facility staff and managers on Resident’s Personal Rights (as articulated in CCLD’s form LIC613C-2). Licensee agreed to E-mail the training sign-in sheet to to LPA by 09-01-2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(c) · Plan of correction due date: Sep 1, 2024

87224 Eviction Procedures: “(c) The licensee shall, in addition to either serving the required thirty (30) days notice…notify or mail a copy of the notice to quit to the resident's responsible person.” This requirement was not met, as evidenced by: Based on records review and interviews, for 1 of 6 residents (R1), Licensee evicted them without serving the required thirty (30) days notice to quit to them and their responsible person. This posed a potential personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: Licensee agreed to utilize a third-party source to retrain the facility administrator on RCFE Eviction Procedure requirements (as described in Regulation 87224). Licensee agreed to E-mail the certiifate of training completion (or equivalent proof) to LPA, by the POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit to check on residents. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Cherry Cook. LPA toured the facility, performed a health and safety welfare check on residents in care, and interviewed staff. No deficiencies were observed or cited on this date. An exit interview was conducted with Cook, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 2, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Ramon Serrano, conducted an announced Pre-Licensing inspection. LPA met with Licensee Cherry Cook and we discussed the purpose of the visit. LPA conducted a tour of the facility, both inside and outside. There are no pools on site. The smoke and carbon monoxide alarms were present. Toilets intended for client use were operating as intended, and bathing facilities were observed to be clean and kempt. The windows, curtains and paint throughout the facility, was observed in good condition. Each room intended for resident use had the appropriate furniture, bedding and appropriate lighting. Licensee Cherry Cook stated there are no firearms stored on the premises. Hot water temperature was measured in the facility at 120 degrees F. The ambient temperature inside the facility was measured at 69 degrees F. The facility was observed to be clean and kempt with no strong malodors. The refrigerator and freezer was observed to be clean and operational, with an ample amount of food to meet client needs. Pre-Licensing is complete and this facility has no deficiencies. An exit interview was conducted with Cherry Cook and a copy of this report along with Licensee Rights was provided to Cherry Cook whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Mar 18, 2024