<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002467
Report Date: 07/09/2024
Date Signed: 07/12/2024 07:54:32 AM

Document Has Been Signed on 07/12/2024 07:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BELLA VISTA CARE HOMEFACILITY NUMBER:
045002467
ADMINISTRATOR/
DIRECTOR:		DELA PAZ, BELLAFACILITY TYPE:
735
ADDRESS:209 MIRA LOMA DRIVETELEPHONE:
(530) 534-1012
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 6CENSUS: DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Bella De La Paz - administratorTIME VISIT/
INSPECTION COMPLETED:
01:25 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
07/09/2024 11:50 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with licensee/administrator Bella De La Paz and explained the purpose of the visit.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) client rooms, common areas, two (2) bathrooms, kitchen, storage areas. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current.

Recreational activities are per client request and abilities. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational. No pools/bodies of water are on premises. The facility has been conducting fire drills every 3 months.

LPA observed 2 of 4 client rooms to be extremely unkempt with clothes strewn all over the rooms, unmade beds, empty food wrappers, empty soda bottles and cans, and empty cups one of which had a large insect in it.

A deficiency is being cited as a result of today’s inspection per Title 22 and is documented on the LIC809-D.

Exit interview conducted and copy of report and appeal rights were provided to administrator Bella De La Paz.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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 2
Document Has Been Signed on 07/12/2024 07:54 AM - It Cannot Be Edited


Created By: Rebecca Knight On 07/09/2024 at 12:54 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELLA VISTA CARE HOME
FACILITY NUMBER: 045002467

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in two out of four client bedrooms which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed 2 of 4 client rooms to be extremely unkempt with clothes strewn all over the rooms, unmade beds empty food wrappers, empty soda bottles and cans, and empty cups one of which had a large insect in it.
POC Due Date: 08/06/2024
Plan of Correction
1
2
3
4
Licensee agrees to clean and organize bedrooms and come up with a plan that the clients will agree to maintain the cleanliness of their rooms or allow staff to help them to maintian the cleanliness of their rooms.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2