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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 371881545
Report Date: 05/01/2026
Date Signed: 05/04/2026 07:19:14 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/24/2026 and conducted by Evaluator Valerie Flores
COMPLAINT CONTROL NUMBER: 18-AS-20260424155717
FACILITY NAME:BELLEVUE VILLAFACILITY NUMBER:
371881545
ADMINISTRATOR:DIZON, CAROLINAFACILITY TYPE:
740
ADDRESS:2080 HEIGHTS COURTTELEPHONE:
(760) 518-8508
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 6DATE:
05/01/2026
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator Carolina DizonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff will not allow resident to be re-admitted into the facility
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20260424155717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BELLEVUE VILLA
FACILITY NUMBER: 371881545
VISIT DATE: 05/01/2026
NARRATIVE
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(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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20260424155717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLEVUE VILLA
FACILITY NUMBER: 371881545
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2026
Section Cited
CCR
87224(a)(5)
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(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
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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.
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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.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3