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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608297
Report Date: 01/15/2025
Date Signed: 01/15/2025 01:09:02 PM

Document Has Been Signed on 01/15/2025 01:09 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 VISTAFACILITY NUMBER:
197608297
ADMINISTRATOR/
DIRECTOR:		BAKER, IANFACILITY TYPE:
740
ADDRESS:1760 N FAIR OAKS AVETELEPHONE:
(626) 794-4103
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 72CENSUS: 49DATE:
01/15/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Ian Baker - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Health Checks visit regarding the repopulation of the residents back in the facility. Administrator stated that on 1/10/2025, residents at Bella Vista 1760 N Fair Oaks Ave., Pasadena, CA. 91103 - License # 197608297 had been relocated to a licensed facility, Glen Park Mariposa, 1220 Mariposa Ave., Glendale, CA. 91205. Additionally, to conduct a health and checks visit regarding the Eaton fire incident on the relocation of (16) residents from a sister facility Bella Vista at Lincoln, 2612 N. Lincoln Ave., Altadena, CA. 91001 - License # 198602253 to Bella Vista 1760 N Fair Oaks Ave., Pasadena, CA. 91103 - License # 197608297 on 1/12/2025. LPA met with Administrator, Ian Baker and explained the purpose of the visit.

During the visit, LPA Pena conducted a health and safety check and no concerns observed. LPA reviewed and obtained the resident and staff rosters for both facilities. Per interview with the Administrator (32) residents of Bella Vista Pasadena repopulated on 01/12/2025. (1) resident is still with family members and is expected to be back in the facility tomorrow, 1/16/2025. LPA toured the facility, inspected random residents' bedrooms and bathrooms. LPA observed (2) pallets of water bottles stored near the dining area and extra cases of bottled water in the second floor. LPA interviewed random residents and indicated that they are aware and were instructed not to use tap water. LPA also observed (2) bottles of water were provided in each residents' bathrooms. The facility has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. The kitchen staff will be serving food using disposable plates and utensils. Administrator will be posting signs on the elevator and common areas to remind residents not to use/consume tap water.

Medications, MARs, and files of the (16) residents that have been transferred to Bella Vista in Pasadena were brought with them and stored in a secured place. All Bella Vista at Lincoln residents are fully ambulatory, use no assistive devices, and do not require any incontinent care. There is sufficient staffing available to provide care for residents of both facilities. ***Continued on LIC 809-C***
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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: 01/15/2025
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Per the Administrator, Pasadena fire inspectors conducted a walk around fire inspection twice at the facility on 01/12/2025 and 1/14/2025 and was given permission to repopulate. Administrator stated that an Ombudsman conducted the visit at the facility twice, on 1/13/2025 and 1/14/2025. It has been verified that a routine fire inspection and testing was completed on 11/03/2024 and fire drill was conducted with staff on 9/10/2024.

Administrator is requesting additional masks and covid testing kits, if available. LPA informed the Administrator to reach out to CCL if any resources or assistance is needed.

An exit interview was conducted and a copy of this report was provided to Administrator Ian Baker.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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