195850662-2-12-2026-29-AS-RDLN-DR8V3Y-20260212150531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850662
Report Date: 02/12/2026
Date Signed: 02/12/2026 03:05:48 PM

Document Has Been Signed on 02/12/2026 03:05 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BELLA VITA SENIOR LIVING		FACILITY NUMBER:	195850662
ADMINISTRATOR/ DIRECTOR:	GABRIELA SOO		FACILITY TYPE:	740
ADDRESS:	145 ANDRE DRIVE		TELEPHONE:	(805) 574-9120
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY: 6		CENSUS: 5	DATE:	02/12/2026
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Gabirela Soo, Licensee/Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:15 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	Licensing Program Analyst (LPA) De Leon conducted an announced Pre-Licensing Change in Ownership visit to the facility above. LPA met with Licensee/Administrator Karoly Budai and Applicant Gabirela Soo and explained the purpose of the visit. LPA conducted a tour with Licensee and Applicant of the physical plant both inside and outside. Infection Control: The facility has sign in and out binders with hand sanitizer at entry. The facility has a 30 day supply of Personal Protective Equipment (PPE). LPA reviewed infection control plan with applicant and the current Licensee has a plan posted in the common area. Trash bins stored outside have coverings. Cleaning and Disinfection will be completed by staff on an ongoing bases. Staff will be trained upon hiring and annually thereafter on infection control and PPE usage. Physical Plant/Environmental Safety: The facility has dual carbon monoxide and smoke detectors present in the common areas of the facility they are hard wired with a sprinkler system. All resident bedrooms have smoke detectors. The facility is clean, safe, sanitary and in good repair. All windows and screen are in good repair throughout the facility. All out door and indoor passageways are clear and no obstructions were observed. The facility is a 4 bedroom, 4 bathroom home with a living room, dining room, kitchen, laundry room, several storage closets and a 3 car garage. Disinfectants, cleaning solutions and laundry products are locked in a key coded laundry room, and locked in a cabinet in the garage. Medications are stored in a locked cupboard in the kitchen. The lighting and lamps through out the facility are for safety and for resident comfort. Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA VITA SENIOR LIVING	FACILITY NUMBER: 195850662
	VISIT DATE: 02/12/2026

NARRATIVE

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Faucets delivering the hot water was tested and measured at 118.7 degrees F. The resident bedrooms have beds, dressers, closet space, lighting, and lamps. Mattress are in good conditions and the facility has plenty of clean linens. The facility has night lights in halls for resident safety. The front yard has a pond that water flows into river rock that has been placed to not allow for water depth. The facility has a back yard with a larger pond that flows with river rock placed to not allow for water depth over a few inches. The outside front entry has a fountain that does not get filled with water and allows for a water feature to be present, applicant will place river rock to not allow depth of water. The outside area has a patio with furniture and shade for residents comfort. The facility has door and window alarms, which are working and identify the area of alarm. The facility has a stairwell off of bedroom #4 the door is kept locked and the facility has a mat not a chair for evacuation, Licensee or Applicant will purchase a new evacuation chair for that stairwell.

Operation Requirements: The facility is currently licensed for a capacity of 6 and currently occupies 5 residents in care. The applicant has submitted for a capacity of 6 with a plan of operation and admission agreement. The fire clearance is approved for 6 bedridden residents. Applicant is pending for a hospice waiver for 6.

Personal Records/Training: All confidential forms and files for staff are stored in a locked key coded closet off of the kitchen.

Client Records/Incident Reports: The residents files are kept confidential and stored in locked key coded closet off of the kitchen. Incident report are completed by Licensee, Administrator. Applicant will send incident reports to CCL when required.

Food Service: The kitchen is clean, safe and sanitary. The facility is kept free of flies, insects and rodents. The freezer is kept at 0 degrees and refrigerator is kept at 40 degrees. The facility currently has 7 days of Non-perishable and 2 day of perishables as well as emergency food and water. Items that can pose danger such as sharps and knives are locked in the kitchen drawer. Cleaning items are stored and locked separately then food supply.

Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA VITA SENIOR LIVING	FACILITY NUMBER: 195850662
	VISIT DATE: 02/12/2026

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Health Related Services: The facility has a first aid kit with manual and all supplies stored in the laundry room cupboards. Centrally stored medication was and will be stored and locked in kitchen cupboards.

Disaster Preparedness: The current disaster plan is posted in the common area of the facility and meets all requirement using the LIC 610D form. Applicant has submitted an new LIC 610D, LPA has reviewed and plan meets regulation requirements. The facility sketch shows all emergency exits. The facility conducts training and quarterly disaster drills covering different scenarios. The facility has plenty of flashlights and batteries for emergencies. The facility has back up food and water supply for emergencies.

Comp III was waived.
Licensee and Applicant will get resident council posted, family council posted, emergency chair for stairwell, river rock added to front fountain and ponds and send LPA photographs to clear the requirements needed. Applicant will be updating admission agreement and submit to the applications Analyst to exclude firearms and ammunition from being brought into the facility..

Exit interview conducted and copy of report printed for Applicant.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

LIC809 (FAS) - (06/04)

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