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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208815
Report Date: 12/28/2023
Date Signed: 12/28/2023 12:53:58 PM


Document Has Been Signed on 12/28/2023 12:53 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, 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) 368-2233
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: 5DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Eric LopezTIME COMPLETED:
01:00 PM
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On 12/28/2023, Licensing Program Analyst (LPA) M. Medina made an unannounced Annual Required Inspection. LPA introduced self, stated purpose of visit, and allowed entrance by care staff. Eric Lopez contacted by telephone and arrived a short time later to conduct inspection.

Currently, five (5) residents in care. Facility tour began in resident bedrooms. Rooms observed to have all required accommodations. All areas of the facility have sufficient lighting. Residents bathrooms observed to be clean and in good repair. Bath/tub are have non-skid mats and grab bars. Hot water tested in both bathrooms with a water temperature of 120 degrees F. Dining room and living room have adequate seating and lighting for all residents in care. Tour of kitchen conducted. LPA observed adequate food supply for the residents in care. LPA observed leftovers stored in the refrigerator and/or freezer observed to be properly stored and labeled. Medications observed to be locked in cabinet in laundry room. All medications observed to have original labels and observed to be administered as prescribed.

Smoke Alarms tested observed operational at time of inspection. Carbon monoxide detector present and observed operational at time of inspection. Fire extinguisher has a service date of 10/03/23. All cleaning supplies observed to be locked and secured in cabinet in garage.

Outside areas toured. All exits open freely and observed to be free of obstruction. No hazards observed.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BELLA VITA AT STONINGTON
FACILITY NUMBER: 157208815
VISIT DATE: 12/28/2023
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Resident and staff files reviewed.

Facility to submit updated LIC 308, LIC 309, LIC 500, LIC 9020, Certificate of Liability Insurance and Administrator certificate to Fresno Regional Office no later than 1/16/2023.

No deficiencies cited.

Exit interview conducted, and copy of report provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
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