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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002467
Report Date: 09/14/2022
Date Signed: 09/14/2022 03:28:57 PM

Document Has Been Signed on 09/14/2022 03:28 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,
, CA
FACILITY NAME:BELLA VISTA CARE HOMEFACILITY NUMBER:
045002467
ADMINISTRATOR:DELA PAZ, BELLAFACILITY TYPE:
735
ADDRESS:209 MIRA LOMA DRIVETELEPHONE:
(530) 534-1012
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 6CENSUS: 4DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Herminia Bernales - Direct Care StaffTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace arrived at the facility unannounced to conduct a Required -1 Year Inspection Visit utilizing the infection control domain. LPA met with direct care staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical masks. Additionally, LPA Wallace was screened by direct care staff. Administrator Certificate expires 12/18/2022.

LPA Wallace and direct care staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, four (4) bathrooms, kitchen, storage areas front yard and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Wallace and the direct care staff completed the infection control domain and facility was found to be in substantial compliance at this time. LPA Wallace completed the infection control domain and facility was found to be in substantial compliance at this time. LPA observed the smoke/monoxide alarms to be in working order and the fire extinguishers are fully charged which expires 12/20/2022. Facility is conducting quarterly fire drills and the last one was conducted 8/16/2022. The hot water measured 112.0*F which is within the required range of 105-120*F.

LPA reviewed 2 of 4 resident records. LPA reviewed medications for 1 resident and is in compliance. LPA reviewed 3 staff records and all have health screen and TB results. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed current first aid certificates and all staff have current first aid certificates.

LPA Wallace completed infection control domain and observed no issues or concerns.


No deficiencies cited today according to California Code of regulations, Title 22.

Exit interview conducted with direct care staff. A copy of reports and appeal rights were given to direct care staff.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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