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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608297
Report Date: 06/30/2025
Date Signed: 06/30/2025 05:24:45 PM

Document Has Been Signed on 06/30/2025 05:24 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: 34DATE:
06/30/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:02 PM
MET WITH:Ian Baker - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent Required- 1 year visit. LPA met with Greg Tillman, Administrative Assistant and explained the purpose of the visit. Shortly after, Ian Baker, Administrator arrived and assisted LPA with the inspection. There are currently thirty four (34) residents residing in the facility. Facility is licensed to serve elderly residents age 60 and above, fire clearance approved for (72) non-ambulatory. Hospice approved for ten (10) residents, 87705 compliant. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

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, Activities room, 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. 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 random resident rooms and water temperature readings measured within the required 105 - 120 degrees Fahrenheit.
Staffing: A total of twenty (20) 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. *****CONTINUED ON LIC809-C*****
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2025
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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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BELLA VISTA
FACILITY NUMBER: 197608297
VISIT DATE: 06/30/2025
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Personnel Records/Staff Training: LPA reviewed (5) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and First Aid/CPR training, however (2) out of (5) staff have expired First aid/CPR training. Administrator's certificate expired on 01/12/2025, but renewal has been submitted.
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: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed the activities calendar posted in the activity room and displayed on the tv screen by the elevator. The facility has a Resident Council.
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. Cleaning supplies are stored in areas separate from food supplies. Sanitation practices and kitchen cleanliness was observed.
Incidental Medical and Dental: Resident medications were reviewed; centrally stored and 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 (5) 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.
Residents with Special Health Needs: No hospice and/or bedridden residents. There are no residents using oxygen. No residents have prohibited health conditions.

Deficiency issued on LIC809-D. An exit interview was conducted, and a copy of this report was provided to Ian Baker, Administrator along with the Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2025 05:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 06/30/2025 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BELLA VISTA
FACILITY NUMBER: 197608297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above in that first aid/CPR training in (2) out of (5) staff files reviewed were expired which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 07/11/2025
Plan of Correction
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Administrator agreed to submit proof of current first aid/CPR training for S1-S2 to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
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