197608297-7-20-2022-28-AS-MVAO-CJHPCU-20220922111231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608297
Report Date: 07/20/2022
Date Signed: 07/20/2022 12:39:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2022 and conducted by Evaluator Christine Wong

COMPLAINT CONTROL NUMBER: 28-AS-20220713171930

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: 32	DATE:	07/20/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ian Baker		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff do not follow Covid-19 quarantine protocols.
Facility staff do not follow Covid-19 PPE protocols.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted an initial complaint investgiation to address the above allegations. LPA met wtih receptionist Linda Whitlock and and explained the reason of the visit and and administrator arrived shortly and assisted with the visit

The investigation consisted of the following: LPA interviewed the administrator, three staff (S1-S3) and four residents (R1-R4) and obtained copy of documents included residents' and staff roster, staff training log for the infection control dated on 7/28/2020 and use of PPE dated on 1/18/2022 and visitors sign in log from July 6 to July 19, 2022

The investigation revealed of the following: Allegation#1 "Facility staff do no follow Covid-19 quarantine protocols. LPA interviewed four residents, three out of four residents denied the allegation and reported no residents walked around during their quarantine or isolation.
(See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20220713171930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/20/2022

NARRATIVE

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Residents reported the Covid-19 positive residents were all stay in their isolation room and only staff went inside and assisted them. LPA interviewed staff and all denied the allegation and reported some residents are mentally incapability and they do not understand about Covid-19, so some may attempt to come out of the isolation room but staff usually would check on them every 5 minutes and ensure they stay inside the isolation room without coming out from the quarantine.

Allegation#2 "Facility staff do not follow Covid-19 PPE protocols." LPA interviewed four residents and all denied the allegation and reported staff did wear the Personal Protective Equipment (PPE) while going inside the isolation room. Staff also denied the allegation and reported they do wear the PPE inside the isolation room and take it off and throw away the PPE while coming out from the isolation room. LPA also observed the staff did wear PPE while going inside the isolation room and there's also a appropriate PPE is located outside of isolation room to prevent contamination with the virus.

Based on the interviews conducted with residents and staff, documents reviewed and LPA's observation, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report and appeal was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2022 and conducted by Evaluator Christine Wong

COMPLAINT CONTROL NUMBER: 28-AS-20220713171930

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: 32	DATE:	07/20/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ian Baker		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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5
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9

Facility staff do not follow Covid-19 masking protocols.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Wong conducted an initial complaint investgiation to address the above allegations. LPA met wtih receptionist Linda Whitlock and and explained the reason of the visit and and administrator arrived shortly and assisted with the visit

The investigation consisted of the following: LPA interviewed the administrator, three staff (S1-S3) and four residents (R1-R4) and obtained copy of documents included residents' and staff roster, staff training log for the infection control dated on 7/28/2020 and use of PPE dated on 1/18/2022 and visitors sign in log from July 6 to July 19, 2022

The investigation revelaed of the following: Allegation "Facility staff do not follow Covid-19 masking protocols." LPA interviewed residents and staff and denied the allegation and reported the staff are required to wear mask.
(See LIC 9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20220713171930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/20/2022

NARRATIVE

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While LPA arrived the facility, LPA observed the staff did not wear mask while talking to the visitor, although there's a divider between the staff and visitor. Also the visitor did not wear the face mask probably which the mask was not covering the nose and staff did not remind the visitor to put the mask on to cover the nose.

Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found Substantiated. California Code of Regulations Title 22,
Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Ian Baker Administrator and a copy of the report, LIC 9099D, and Appeal Rights was provided

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20220713171930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/03/2022 Section Cited CCR 87470(c)(1)(F)	1 2 3 4 5 6 7	87470 nfection Control Requirements (c)An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The infection control plan shall include of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.	1 2 3 4 5 6 7	The administrator will ensure the facility is following infection control plan and the administrator will retrain the staff about the infection control and send the staff training log to LPA by POC due date.
	8 9 10 11 12 13 14	The requirement is not met as evidenced by: LPA observation, LPA observed S2 did not wear mask while talking to the visitor which posed an potential risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC9099 (FAS) - (06/04)

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