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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201202
Report Date: 11/10/2023
Date Signed: 11/10/2023 04:16:03 PM

Document Has Been Signed on 11/10/2023 04:16 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 VISTAFACILITY NUMBER:
019201202
ADMINISTRATOR:BAUTISTA, HAIDIEFACILITY TYPE:
740
ADDRESS:1641-1659 D STREETTELEPHONE:
(510) 397-0751
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 42CENSUS: 35DATE:
11/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Haidie Bautista/AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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On this day, November 10, 2023, at 10:15 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with staff, Efren Moreno, Sally Espina, Nangtin Lwin. LPA called and spoke over the phone with Haidie Bautista, administrator, and informed the reason for visit. Administrator arrived after several minutes.

Facility has LIC9282 Infection Control Plan.

LPA started the inspection with Sally Espina and continued with Haidie Bautista. LPA inspected the 2 buildings (Bldg A and Bldg B) including but not limited to common areas, kitchen, dining areas, receiving room, library, staff room, bathrooms, shower rooms, toilets and yard. LPA selected for inspection 3 residents rooms in each in Bldg A and Bldg B. 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. All residents rooms, dining and common areas were equipped with electric fans. Hallways, common areas, yards and 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 was tested and measured at 119 and 120 degrees Fahrenheit. Facility conducts fire drills every quarter and records showed last conducted October 1, 2023.


.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 11/10/2023
NARRATIVE
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LPA reviewed 5 residents and 3 staff files, and interviewed 3 staff and 3 residents. Medications were checked and compared with records. Facility does not handle residents' cash resources.

Administrator to submit a copy of updated LIC500 Personnel Report by 11/24/23.

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.

-at 10:43 am, medications in unlocked staff room.
-at 12:51 pm, staff S3 has no first aid and 4 hours postural support/restricted health/hospice care training.

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: 11/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/10/2023 04:16 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/10/2023 at 03:21 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: 11/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above for S3 not having the reqjuired training which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 11/24/2023
Plan of Correction
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Administrator stated she'll have the staff trained. Proof to be submitted by 11/24/23.
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for S3 not having first aid training which poses a potential health and/or safety risks to persons in care.
POC Due Date: 11/24/2023
Plan of Correction
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Administrator to have the staff trained and submit copy of certificate by 11/24/23.
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: 11/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/10/2023 04:16 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/10/2023 at 03:48 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: 11/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for staff medications in unlocked which poses an immediate health and/or safety risks to persons in care.
POC Due Date: 11/11/2023
Plan of Correction
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Staff locked the room.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/11/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2023


LIC809 (FAS) - (06/04)
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