Bellevue Villa

Type of visit: Case Management - Deficiencies

On 9/3/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility. During the visit, LPA Flores observed immediate health and safety concerns. Below is a summary of LPA Flores' observations: LPA Flores was granted entry into the home by Uncleared Individual #1 (UI1). Upon further observations, LPA observed resident paperwork that covered the dining table. In the kitchen, LPA observed the counter tops to be unorganized and covered with cookware, food items, and utensils. LPA observed that a resident was living a common area (living room). Residents were observed watching television in the living room which does not allow Resident #2 (R2) privacy. In addition, R2 maintained medication and scissors on a bedside table which were easily accessible to the residents with cognitive impairments. Passageways were obstructed by furniture, supplies, and other items; making it difficult to maneuver for non-ambulatory residents. Bedroom A, intended use for residents, was being used as storage. Supplies and other items cluttered the room, making it difficult to fully open the bedroom door. LPA observed (3) three individuals in the home who identified themselves as staff. The (3) three individuals did not have background clearance to be residing nor providing care to the residents. In addition, LPA observed a total of (10) ten residents in the home. Per the Licensee, the residents "did not belong to me" and are clients of a recuperative care based out in Apple Valley and are temporarily receiving housing placement in the Licensee's licensed facility. Upon speaking with residents, residents confirmed that they are receiving some scope of care and supervision from the Licensee and the Licensee's employed staff. In addition, Resident #3's (R3) closet door was off the broken off and observed to be leaning on the wall. Therefore, deficiencies will be issues and civil penalties will be accessed according to California Code of Regulation, Title 22. An exit interview was conducted and a copy of this report was provided to the Licensee.the state’s words, verbatim · CDSS document, Sep 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(b) · Plan of correction due date: Sep 4, 2026

(b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met with evidence by (3) three persons who identify themselves as staff reported... ... to be working at the facility but did not have documentation of a criminial record clearance being conducted before-hand.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee agreed to have the uncleared individuals background and fingerprint cleared to the facility. Licensee will begin the process no later than on COB on 9/4/2026. Plan of Correction cannot be complete until all persons have been properly cleared and associated.

From the deficiency page — Deficiency type: Type A · Section cited: HSC87204(a) · Plan of correction due date: Sep 5, 2026

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. This requirement was not met with evidence by: LPA learned that there are a ... total of (10) ten residents residing in the home. The facility is only approved for (6) six residents.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee did not provide a Plan of Correction during the time of visit. LPA will be cordinating with Licensing Program Managers and Regional Managers for additional guidance.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(2)(B) · Plan of correction due date: Sep 17, 2026

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This requirement was not met with evidence by: A resident bedroom was set up in the family... room which is also used as the primary place where other residents watch television on the couch.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee agreed to relocate Resident #2 (R2) into a bedroom within two weeks. Proof of Correction may be satified by photo proof. Photo proof shall be provided to LPA no later than COB on 9/17/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(d)(2) · Plan of correction due date: Sep 17, 2026

(d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met with evidence by: Resident #3 (R3) closet door was broken and was left leaning.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee agreed to repair R3's closet door by COB on 9/17/2026. Proof of Correction may be satified by photo proof. Photo proof shall be provided to LPA no later than COB on 9/17/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Sep 17, 2026

(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met with evidence by: furniture, supplies, other items blocked passageways.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee agreed to remove the unneccessary furniture from the home and will clean up Building A. Proof of Correction may be satified by photo proof. Photo proof shall be provided to LPA no later than COB on 9/17/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Sep 17, 2026

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as Licensee reports that they do not have records for.. the clients living in the home because the Licensee is allowing a person to place their clients in the home temporarily but is still providing care and supervision to these clients under the Licensee's license.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee did not provide a Plan of Correction during the time of visit. LPA will be cordinating with Licensing Program Managers and Regional Managers for additional guidance.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(c) · Plan of correction due date: Sep 17, 2026

(c) All information and records obtained from or regarding residents shall be confidential. This requirement was not met with evidence by: Licensee left multiple residents medical documentation unaccompanied on the dining room table.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee agreed to remove all confidential information from the dining room table and place them in a secure location. POC may be satified by photo proof and provided to LPA not later than COB 9/17/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Sep 17, 2026

No licensee... shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility; This requirement was not met with evidence by: Licensee reports they are operating as a room and board although interviews conducted report otherwise.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee did not provide a Plan of Correction during the time of visit. LPA will be cordinating with Licensing Program Managers and Regional Managers for additional guidance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 4, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in a locked storage and are not left unattended if outside... the locked storage. This requirment was not met with evidence by: Resident #2 (R2), who is residing a common area, was observed to have scissor left on the bedside table; easily accessible to the residents with cognitive impairment.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee agreed to provided a secured area while R2 is relocating into a bedroom. POC may be satified by photo proof and provided to LPA not later than COB 9/17/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(C) · Plan of correction due date: Sep 4, 2026

(h) The following requirements shall apply to medications which are centrally stored: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either... a physician, the administrator, or Department to be a safety hazard to others. This requirement was not met with evidence by: R2, who is residing in a common area, has their medication easily accessible to the residents with cognitive impairment.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee agreed to provided a secured area while R2 is relocating into a bedroom. POC may be satified by photo proof and provided to LPA not later than COB 9/17/2026.

Allegation investigated: Staff will not allow resident to be re-admitted into the facility

On 5/1/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of launching the complaint investigation into the allegation listed above. LPA Flores met with Administrator Carolina Dizon and explained the purpose of the visit. The investigation is summarized as follows: Information received alleged staff did not allow Resident #1 (R1) to be re-admitted into the facility. Witness #1 (W1) reports that facility staff had R1 transported to the hospital and are now refusing to accept R1 back into the facility. W1 reports that R1 was not issued an eviction notice. LPA Flores attempted to speak with W1 via telephone, but attempt were unsuccessful. Interviews with Staff #1 (S1) reports that R1 was placed into the home under an emergency placement. S1 reports that they were misled by R1’s current condition as the placement agency reported R1 to be independent. After R1 was placed into the facility, staff began observing behaviors that were not previously divulged. (Continue to LIC9099C) Substantiated (Continuation from LIC9099) S1 reports that R1 would refuse care assistance and would smoke inside the bedroom. During the visit, LPA requested R1’s file but was advised that the facility did not maintain documentation for R1 as R1 was placed into the facility on a temporary status. Administrator further confirmed that a pre-placement appraisal or admission agreement was not created for R1. Administrator reports that an eviction notice was not provided to R1 as R1 was placed into a different board and care. Administrator did not have a direct contact number for R1. LPA was unable to conduct an interview with R1 as LPA was not provided a telephone number or the name of the board and care R1 was placed into. Therefore, the allegation of staff will not allow resident to be re-admitted into the facility is deemed substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid as the preponderance of the evidence standard has been met. California Code of Regulations Title 22 is being cited on the attached LIC9099D. During the investigation, LPA learned of additional health and safety concerns which will be documented on a LIC809 Case Management visit. An exit interview was conducted and a copy of the LIC9099, LIC9099C, LIC9099D, and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, May 1, 2026 · control 18-AS-20260424155717

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(5) · Plan of correction due date: May 15, 2026

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...(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, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement was not met with evidence by: (1) one out of (6) six residents were unlawfully evicted from the facility.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: Administrator agreed to conduct a training from an outside provider pertaining to Health and Safety Section 1569.682 and Title 22 Regulation Section 87224. Proof of tarining will be submitted to LPA Flores but close of business 5/15/2026.

Type of visit: Case Management - Deficiencies

On 5/1/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of launching the complaint investigation into complaint control number 18-AS-20260424155717. LPA Flores met with Administrator Carolina Dizon and explained the purpose of the visit. During the visit, LPA learned that the Licensee did not conduct a pre-placement appraisal for Resident #1 (R1), did not have a signed admission agreement for R1, or any other required documents as required by Title 22, Section 87506 which posed an health and safety risk to R1. Therefore, a deficiency was issued on the attached LIC809D. An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, May 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: May 15, 2026

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met with evidence by: (1) one out of (6) six residents did not have a file for the required documents listed in Title 22, Section 87506.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: Administrator agreed to receive and complete a training on Title 22, Section 87506. Proof of completion will be forwarded to LPA Flores via email by close of business on 5/15/2026.

Type of visit: Required - 1 Year

On 03/25/2026 Licensing Program Analyst (LPA) Jacqueline Shaw-Ross made an unannounced visit to the facility to conduct an annual inspection. LPA met with Administrator, Carolina Dizon, and the purpose of the visit was explained. The facility serves residents aged 60 and above, 6 ambulatory, of which 6 may be non-ambulatory. A waiver has been granted for hospice care for 3 residents. At the time of visit there were 2 staff present and 5 residents presents. The facility is single story structure and consists of a garage, backyard with plenty of space to walk and participate in outdoor activities, kitchen, (5) bedrooms and (4) bathrooms. The facility was observed to possess a Solar generator in the event of a power outage. The facility had required postings throughout the home. LPA observed 4 fire extinguishers to be fully charged. The facility was observed to have a sufficient food supply of 2 day of perishable and a 7 day supply of nonperishable food items. Medications, sharps, and cleaning chemicals were locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were tested and operable. Quarterly emergency disaster drills are being conducted as required, last one was in March 2026. During tour, LPA observed door handle on refrigerator door to be broken, Technical Advisory given. The facility bathrooms are equipped with non skid mats, grab bars and shower chairs. The resident bedrooms were observed to have adequate lighting, clean linen, chest of drawers, and chairs. The hot water temperature was observed to be within regulatory limits measuring at 110 degrees Fahrenheit. The medications are being stored inside a locked cabinet inside the kitchen next to the refrigerator, and were observed to be administered per physicians orders. LPA reviewed staff files and all files were complete. A sample of resident files were reviewed and also contained all required documents. There are no pools or bodies of water or known guns or ammunition on the premises. LPA reviewed first aid kit and it contains required items. No deficiencies were observed during today's visit. A copy of this report was provided to Administrator Carolina Dizon.the state’s words, verbatim · CDSS document, Mar 25, 2026

Type of visit: Prelicensing

On 02/06/2025 Licensing Program Analyst (LPA) Javina George made an announced visit to the facility to conduct a prelicensing inspection. LPA met with Applicant Carolina Dizon whom accompanied LPA throughout today's inspection. The applicant has applied for a Change of Ownership (CHOW), Residential Care for the Elderly (RCFE), aged 60 and above. On 10/22/24 the Escondido Fire Department approved the facility for (6) non ambulatory residents ,of which no residents can be bedridden. The facility does not have an approved fire clearance to retain bedridden residents. The facility is single story structure and consists of a garage, backyard with plenty of space to walk and participate in outdoor activities, kitchen, (5) bedrooms and (4) bathrooms. The facility was observed to possess a Solar generator in the event of a power outage. In addition to have the required postings, and operable smoke and carbon monoxide detectors, and (4) fully charged fire extinguishers. The facility was observed to have a sufficient food supply of 2 day of perishable and a 7 day supply of nonperishable food items. The facility is equipped with non skid mats, grab bars and shower chairs. The resident bedrooms were observed to have adequate lighting, clean linen, chest of drawers, and chairs. The hot water temperature was observed to be within regulatory limits measuring at 108.6-110 degrees Fahrenheit. The medications are being stored inside a locked cabinet inside the kitchen next to the refrigerator. The staff and resident files are locked inside a file cabinet inside the kitchen/common area. There are no pools or bodies of water or known guns or ammunition on the premises. The facility was observed to possess valid liability insurance with an expiration date of 01/06/26. The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22 Chapter 6, Division 8. The applicant is scheduled to complete COMP III orientation on 02/11/25. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure. An exit interview was conducted and a copy of this report was provided to Carolina Dizon.the state’s words, verbatim · CDSS document, Feb 6, 2025

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 6 Census (if any clients in care): 4 COMP II Participants: CAROLINA DIZON Interview Method: Telephone interview On January 27, 2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 27, 2025