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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881545
Report Date: 09/03/2026
Date Signed: 09/03/2026 03:19:54 PM

Document Has Been Signed on 09/03/2026 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BELLEVUE VILLAFACILITY NUMBER:
371881545
ADMINISTRATOR/
DIRECTOR:		DIZON, CAROLINAFACILITY TYPE:
740
ADDRESS:2080 Heights CTTELEPHONE:
(760) 294-8086
CITY:EscondidoSTATE: CAZIP CODE:
920274751
CAPACITY: 6CENSUS: 10DATE:
09/03/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensee Carolina DizonTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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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.
Anthony Perez
Valerie Flores
DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/03/2026 03:19 PM - It Cannot Be Edited


Created By: Valerie Flores On 09/03/2026 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BELLEVUE VILLA
FACILITY NUMBER: 371881545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2026
Section Cited
CCR
87355(b)

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(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...
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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.
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... to be working at the facility but did not have documentation of a criminial record clearance being conducted before-hand.
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Type A
09/05/2026
Section Cited
HSC87204(a)

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(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 ...
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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.
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total of (10) ten residents residing in the home. The facility is only approved for (6) six residents.
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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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 03:19 PM - It Cannot Be Edited


Created By: Valerie Flores On 09/03/2026 at 12:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BELLEVUE VILLA
FACILITY NUMBER: 371881545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2026
Section Cited
CCR
87307(2)(B)

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(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...
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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.
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room which is also used as the primary place where other residents watch television on the couch.
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Type B
09/17/2026
Section Cited
CCR87307(d)(2)

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(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.
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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.
Type B
09/17/2026
Section Cited
CCR
87307(d)(6)

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(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.
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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.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 03:19 PM - It Cannot Be Edited


Created By: Valerie Flores On 09/03/2026 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BELLEVUE VILLA
FACILITY NUMBER: 371881545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2026
Section Cited
CCR
87506(a)

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(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..
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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.
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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.
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Type B
09/17/2026
Section Cited
CCR87506(c)

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(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.
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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.
Type B
09/17/2026
Section Cited
CCR
87207

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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.
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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.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 03:19 PM - It Cannot Be Edited


Created By: Valerie Flores On 09/03/2026 at 01:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BELLEVUE VILLA
FACILITY NUMBER: 371881545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2026
Section Cited
CCR
87309(a)

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(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...
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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.
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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.
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Type A
09/04/2026
Section Cited
CCR87465(h)(C)

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(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...
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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.
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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.
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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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


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