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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208815
Report Date: 12/20/2021
Date Signed: 12/21/2021 01:56:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BELLA VITA AT STONINGTONFACILITY NUMBER:
157208815
ADMINISTRATOR:LOPEZ, ERICFACILITY TYPE:
740
ADDRESS:11711 STONINGTON STREETTELEPHONE:
(661) 319-6103
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: 3DATE:
12/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Staff Sonia DimasTIME COMPLETED:
02:13 PM
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Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Insepction visit. LPA Williams met with Staff, Sonia Dimas, and discussed the purpose of the visit. LPA Williams spoke with Administrator, Eric Lopez, via phone and discussed the purpose of the visit.

LPA Williams toured the facility with staff.

LPA Williams observed a mask and sanitizer at the front entrance. LPA Williams advised staff and Administrator to place a visitor and temperature check log at the front entrance. Facility has one entry and exit point. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies and medication were observed behind a locked door. Facility has the following Personal Protective Equipment available in storage; masks, gloves, gowns, and face shields.

Staff have received training in Covid-19 mitigation and infection control. 2 of 3 residents files had up to date emergency contact information. LPA Williams advised Administrator to ensure staff have access to emergency contact information for all residents.

Licensee shall submit the following documents to Community Care Licensing by 12/28/2021: Personnel Report (LIC 500), Designation of Facility Responsibility (LIC 308), transcribed Covid Mitigation Plan (LIC 808), and Administrator Certificate.

No deficiencies were cited at this time, an exit interview was conducted, and a copy of this report will be provided via e-mail.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
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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