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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002895
Report Date: 05/23/2024
Date Signed: 05/23/2024 11:48:26 AM

Document Has Been Signed on 05/23/2024 11:48 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 VIDA CENTERFACILITY NUMBER:
045002895
ADMINISTRATOR/
DIRECTOR:		WEBSTER, SIMONIEFACILITY TYPE:
772
ADDRESS:556 COHASSET ROADTELEPHONE:
(916) 870-9676
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY: 10CENSUS: 3DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:19 AM
MET WITH:Administrator- Simonie WebsterTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 05/23/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Simonie Webster and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free. LPA observed all resident bedrooms to have the required furnishings, windows with screens and working lights. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. LPA observed three (3) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed all medications to be locked and inaccessible to residents. LPA observed all of the required postings within the facility.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of three (3 ) residents' files and four (4) staff files. Resident files contained all the required documentation. Of the four staff files, one staff file was missing the medical assessment and TB test. LPA observed a completed emergency disaster plan with fire drills conducted as required. LPA observed a completed emergency first aid kit ready for emergency use.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.


Several topics were discussed.

An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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Document Has Been Signed on 05/23/2024 11:48 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 05/23/2024 at 11:36 AM
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 VIDA CENTER
FACILITY NUMBER: 045002895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81066(c)(10)
Personnel Records
(c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 81065(g).

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 in one out of four files reviewed did not have a health screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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The administrator will ensure that the staff obtain a helath screening before returning to work. Administrator will create a plan to ensure that all staff obtain a health screening before starting work at the facility and will share that plan with the LPA>
Type B
Section Cited
CCR
81066(c)(11)
Personnel Records
(c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 81065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based record review, the licensee did not comply with the section cited above in one out of four files reviewed were missing the TB testing and results which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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The administrator will ensure that the staff obtain a TBtest before returning to work. Administrator will create a plan to ensure that all staff obtain a TB Test before starting work at the facility and will share that plan with the LPA
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:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024


LIC809 (FAS) - (06/04)
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