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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608297
Report Date: 07/02/2021
Date Signed: 07/02/2021 02:18:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BELLA VISTAFACILITY NUMBER:
197608297
ADMINISTRATOR:BAKER, IANFACILITY TYPE:
740
ADDRESS:1760 N FAIR OAKS AVETELEPHONE:
(626) 794-4103
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:72CENSUS: DATE:
07/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Office Administrator / Truley Stephanie
Licensee Representative / Ann Hamilton
Administrator / Ian Baker		TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Nune Margaryan and Joe Katrdzhyan conducted an announced Required - 1 Year inspection. Upon arriving at the facility, LPAs met with Stephanie Truley and Ann Hamilton and were later joined by the Administrator Ian Baker, who assisted with the visit.
The facility is licensed to serve seventy-two (72) Non-Ambulatory residents ages 60 and above. The facility has an approved Hospice Waiver on file for ten (10) residents. Currently there are no Residents on Hospice. Bella Vista has an approved Dementia Plan of Operation. Facility handles residents’ finances.

The facility has two levels. All business offices and the kitchen are located on the first floor. The resident rooms, medication room, laundry room, activity/television room, beauty shop, library and a dining room are located on the second floor.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPAs were screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

During today's visit, with the assistance of Administrator Ian Baker LPAs toured the physical plant areas inside and out to ensure there are no health and safety hazards and Physical Plant is in compliance with Title 22 Regulations. The facility has central air and heating accommodations. LPAs toured a randomly selected resident rooms. All bedrooms were furnished with required furniture. The signal system was tested in various locations.

Please see LIC 809C for additional information
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BELLA VISTA
FACILITY NUMBER: 197608297
VISIT DATE: 07/02/2021
NARRATIVE
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The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water temperature was tested. The kitchen was inspected. LPAs observed kitchen equipment to be clean and in working condition. LPAs observed the food supply stored at the facility. There was a sufficient quantity of the various perishable and non-perishable food supplies. No pesticides or poisons were stored in the food areas.

The fire extinguishers observed to be fully charged. Smoke/carbon monoxide detectors were observed to be fully operational. The front yard of the facility is well landscaped and have a leveled walkway to the entrance. The outdoor area was enclosed and no bodies of water were observed. The Administrator's certificate is current.

The following deficiencies were observed during this visit.

  • During todays visit LPAs observed the auditory chimes located on both exit doors in the south side of the bulling were inoperable.
  • Between 9:45 am to 10:45 am LPAs observed: Shared bathroom (R#5, R#6) - 71.6 F Shared bathroom (R#28, R#29) - 125 F R#2 - 72.3 F; R#9 - 69.8 F; R#18 - 95 F.
  • LPAs observed missing widow screens on bathroom windows located in rooms #5 and #10, located on the north side of building. Window screens were observed full of cobwebs and dust throughout the facility.
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The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)


An exit interview was conducted and a copy of this report was provided to the Director along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA VISTA
FACILITY NUMBER: 197608297
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2021
Section Cited

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Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by;
During todays visit LPAs observed the auditory chimes located on both exit doors in the south side of the bulling were inoperable.
Type A
07/06/2021
Section Cited

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Maintenance and Operation. Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degrees F
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49 degree C).
This requirement is not met as evidenced by;
Between 9:45 am to 10:45 am LPAs observed: Shared bathroom (R#5, R#6) - 71.6 F Shared bathroom (R#28, R#29) - 125 F R#2 - 72.3 F; R#9 - 69.8 F; R#18 - 95 F.
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Type B
07/23/2021
Section Cited

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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
LPAs observed missing widow screens on bathroom windows located in rooms #5 and #10, located on the north side of building. Window screens were observed full of cobwebs and dust throughout the facility.
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: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2021
LIC809 (FAS) - (06/04)
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