019201202-7-19-2023-15-AS-ADEO-CTW4GC-20230719190519

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019201202
Report Date: 07/19/2023
Date Signed: 07/19/2023 07:05:52 PM

Document Has Been Signed on 07/19/2023 07:05 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	BELLA VISTA		FACILITY NUMBER:	019201202
ADMINISTRATOR:	BAUTISTA, HAIDIE		FACILITY TYPE:	740
ADDRESS:	1641-1659 D STREET		TELEPHONE:	(510) 397-0751
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY: 42		CENSUS: 38	DATE:	07/19/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Haidie Bautista/Administrator		TIME COMPLETED:	07:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day, July 19, 2023, at 1:00 p.m, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA was granted entry by House Manager Sally Espina. LPA met with Haidie Bautista, administrator, and informed the reason for visit. Facility has LIC9282 Infection Control Plan. LPA toured the facility inside out with the administrator. LPA inspected the 2 buildings (Bldg A and Bldg B) including but not limited to common areas, kitchen, dining areas, receiving room, library in Bldg B, bathrooms, shower room, toilets and yard. LPA selected 3 and 2 residents rooms in Bldg A and Bldg B respectively for inspection. Fire extinguishers were observed fully charge with tags showed serviced March 16. 2023. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and medication carts were locked. Cabinets/drawers for knives were locked. All residents rooms, dining and common areas were equipped with electric fans. Hallways, common areas, porch were observed free of hazards. Facility has smoke and carbon monoxide detectors that were observed functional. Hot water temperature in bathrooms in Bldg A and Bldg B were tested, and measured at 108.7 and 115 degrees Fahrenheit respectively. Facility conducts disaster drills, and records showed last conducted April 1, 2023. LPA reviewed 5 residents and 5 staff files, and interviewed 3 staff and 3 residents. Medications were checked and compared with records. Facility does not handle residents' cash resources. .......continued on 809C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELLA VISTA	FACILITY NUMBER: 019201202
	VISIT DATE: 07/19/2023

NARRATIVE

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LPA observed the following:
-at 5:05 pm residents (R1, R2. R3, R4 and R5) Appraisal on file were over a year old.
-at 5:15 pm, resident's (R4) LIC602A indicated dependent on others with all activities of daily living; however. R4 can feed self. LIC602A is over a year old.

LPA received the following updated documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC610E Emergency Disaster Plan (9 pages)
3. Proof of $3M liability insurance coverage

Administrator to submit copy of updated LIC500 Personnel Report by 8/02/23.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/19/2023 07:05 PM - It Cannot Be Edited

Created By: Alicia Delmundo On 07/19/2023 at 06:34 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELLA VISTA	FACILITY NUMBER: 019201202
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above. Four residents appraisals are over a year old which pose potentiial health and/or personal rights risk to persons in care.
	POC Due Date: 08/02/2023
	Plan of Correction
1 2 3 4	Administrator stated she'll do the re-sppraisals and submit self-certification by 8/02/23.

Type B

Section Cited

CCR

8888

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. R4's LIC602A and reappraisal are over a year old. The LIC602A also indicated R4 is dependent on all ADLs; however, R4 can feed self. These pose potential health and/or personal rights risk to person
	POC Due Date: 08/02/2023
	Plan of Correction
1 2 3 4	Administrator to set-up an appointment and have the LIC602A and appraisal updated. Proof to be submitted by 8/02/23.

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:

Bennett Fong

LICENSING EVALUATOR NAME:

Alicia Delmundo

LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC809 (FAS) - (06/04)

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