197608297-5-9-2024-28-AS-BPEA-D54U8B-20240509152115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608297
Report Date: 05/09/2024
Date Signed: 05/09/2024 03:22:28 PM

Document Has Been Signed on 05/09/2024 03:22 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	BELLA VISTA		FACILITY NUMBER:	197608297
ADMINISTRATOR:	BAKER, IAN		FACILITY TYPE:	740
ADDRESS:	1760 N FAIR OAKS AVE		TELEPHONE:	(626) 794-4103
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	72	CENSUS: 35	DATE:	05/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Ian Baker - Administrator		TIME COMPLETED:	03:04 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 Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs met with Lynda Whitlock, Receptionist and explained the purpose of the visit. At 9:45am, Administrator, Ian Baker arrived and assisted LPAs with the visit. There are currently thirty five (35) residents 60 years and older residing in the facility. Facility is licensed to serve elderly residents age 60 and above, fire clearance approved for (72) non-ambulatory. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed.  There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has covid-19 digital signage TV screen above the elevator. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Facility is approved for (10) hospice residents, 87705 compliant. A fire clearance is in place. Fire Drill was last conducted on 3/27/2024. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 10/17/2024. Surety bond in the amount of $65,000 is current and expires 12/01/2024. Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: Lobby, Administrative offices, Conference room, Supply room, Power/Telephone room, Kitchen, Janitor room and Elevator. Second floor: (36) resident bedrooms, Medication room, Library, Staff room, Beauty shop, Doctor's office/Nurse station and Dining room. The interior and exterior physical plant was inspected. Kitchen was inspected, knives, sharps objects, cleaning supplies and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. The patio furniture in the backyard did not have umbrellas, but there is an area that provides shade. Laundry area was inspected and one of the washing machines was broken, missing a door.There are cameras without audio in the hallways and common areas. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. LPAs tested hot water temperature in five (5) random resident rooms and water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 95.3 deg F and 119.8 deg F.: Room #8 - sink faucet broken, dripping hot water only Room #9 - observed insects, drain flies in the bathroom Room #20 - 119.8 deg F Room #23 - 105.2 deg F Room #35 - 95.3 deg F, room has no window covering in the bathroom Room #32 - 101.3 deg F

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA VISTA	FACILITY NUMBER: 197608297
	VISIT DATE: 05/09/2024

NARRATIVE

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Staffing: A total of twenty seven (27) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: LPA reviewed four (4) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator Ian Baker's certificate expires on 01/12/2025.
Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. LPAs observed the activities calendar posted in the activity room. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities.
Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed.
Incidental Medical and Dental: Four (4) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided.
Resident Records/Incident Reports: Resident files are maintained at the facility. A total of four (4) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted.
Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Fire drill is conducted on a monthly basis and last fire drill was conducted on 03/13/2024.
Residents with Special Health Needs: Half bed rails for mobility assistance were observed in some resident beds. LPAs observed 1/2 bedrail in C2's bedroom and facility cannot provide a written order from C2's physician. "Oxygen In Use" signs were posted on the resident doors who are using oxygen.

Deficiencies issued on LIC809-D. An exit interview was conducted, and a copy of this report was provided to Greg Tillman, Administrative Assistant along with the Appeals Rights.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/09/2024 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA VISTA	FACILITY NUMBER: 197608297
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) 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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in which (2) out of (5) random resident rooms inspected did not meet the required water temperature readings. Room #32 (101.3 deg F) and Room #35 (95.3 deg F) which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	Administrator will submit a 7-day log of water temperature in Rooms #32 & #35 and ensure that the water readings are within Title 22 Regs. Log to be submitted to CCL/LPA by POC due date.

Type B

Section Cited

CCR

87303(f)(1)

Maintenance and Operation

(f) Solid waste shall be stored and disposed of as follows: (1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that LPAs observed drain flies inside the bathroom in Room #9 which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	Administrator will submit a copy of the invoice and service report from pest control company to CCL/LPA by POC due date.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/09/2024 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA VISTA	FACILITY NUMBER: 197608297
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(g)(1)

Maintenance and Operation

(g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair. Space used to sort soiled linen shall be separate from the clean linen storage and handling area. Except for facilities licensed for fifteen (15) residents or less, the space used to do laundry shall not be part of an area used for storage of anything other than clean linens and/or other supplies normally associated with laundry activities. Steam, odors, lint and objectionable laundry noise shall not reach resident or employee areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that one of the washing machines in the laundry room is inoperable and missing a door which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	Administrator will send a copy of the invoice from the service technician to show that the washing machine has been replaced or fixed. Invoice/report to be submitted to CCL/LPA by POC due date.

Type B

Section Cited

HSC

1569.695(f)(1)

Other Provisions

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that the facility does not have an evacuation chair at each stairwell available to facility staff during an emergency which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	Administrator will submit a proof of purchase of the evacuation chair and submit photos that it had been installed in the stairwell. Proof of purchase and photos to be submitted to CCL/LPA by POC due date.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 05/09/2024 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA VISTA	FACILITY NUMBER: 197608297
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the Administrator did not comply with the section cited above in that LPAs observed 1/2 bedrail in C2's bedroom (Room #8) and facility cannot provide a written order from C2's physician which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	Administrator to submit a copy of the Physician's order for the 1/2 bedrail for C2 to CCL/LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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