<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608297
Report Date: 09/07/2022
Date Signed: 10/06/2022 03:02:49 PM


Document Has Been Signed on 10/06/2022 03:02 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:BAKER, IANFACILITY TYPE:
740
ADDRESS:1760 N FAIR OAKS AVETELEPHONE:
(626) 794-4103
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:72CENSUS: 34DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee Representative Ann Hamilton
Administator Assistant Monique Jordan		TIME COMPLETED:
03:45 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) Yating Yang and Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility LPAs met with the Licensee representative Ann Hamilton and were later joined by the Administrator Assistant Monique Jordan who assisted with the visit. The facility is licensed to serve elderly residents age 60 and above. Fire clearance was approved for seventy-two (72) non-ambulatory residents. Hospice was approved for ten (10) residents. Currently NO residents are on Hospice. During today's visit, LPAs used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies were reviewed.

The interior and exterior physical plant was inspected. There is only one entrance being utilized at the facility. COVID -19 related materials were posted on the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. A tour of the two story facility includes: All business offices and the kitchen, located on the first floor and resident rooms, bathrooms, common restrooms, shower rooms, medication room, laundry room, linen cabinets, activity/television room, beauty shop, library and a dining room, located on the second floor.

During today's visit, 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 the second floor and randomly selected #9 resident rooms. All selected bedrooms were furnished with required furniture with operational call lights. Some bedrooms have private bathrooms and some have shared bathrooms. The auditory chimes at the exit doors were tested during the visit.




Continue on LIC 809C
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: YaTing YangTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BELLA VISTA
FACILITY NUMBER: 197608297
VISIT DATE: 09/07/2022
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
26
27
28
29
30
31
32
The bathrooms were observed to be clean, operational and equipped with grab bars and paper supplies. The hot water temperature was tested throughout the facility and measured within compliance of Title 22 Regulations. 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 were observed to be fully charged and in compliance LPAs observed multiple pull-switch fire alarms throughout the facility. Smoke/carbon monoxide detectors were observed to be operational. The front yard of the facility is well landscaped and has a leveled walkway to the entrance. The outdoor area was enclosed and no bodies of water were observed. All residents medications were centrally stored and four of them were reviewed and the medications were administered as prescribed.

The following deficiencies were observed during this visit:


1. Two bottles of the laundry detergent were found in the laundry room left accessible to residents, which poses immediate health and safety risks to the residents in care.

2. One private bathroom in room #20 has no running hot water. The staff will move the resident to another room temporarily until the plumber fixes the issues The plumber is scheduled to come out on 9-8-22

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) 981-3969
LICENSING EVALUATOR NAME: YaTing YangTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/06/2022 03:02 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: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2022
Section Cited

1
2
3
4
5
6
7
Care of Persons with Dementia The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
8
9
10
11
12
13
14
This requirement is not met as evidenced by;
During today vist, LPAs oberserved two bottles of the laundry detergent in the laundry room left accessible to residents, which poses immediate health and safety risks to the residents in care.
8
9
10
11
12
13
14
Type B
09/09/2022
Section Cited

1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
During today visit, LPAs observed one private bathroom in room #20 has no running hot water. The staff will move the resident to another room temporarily until the plumber fixes the issues The plumber is scheduled to come out on 9-8-22
8
9
10
11
12
13
14
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) 981-3969
LICENSING EVALUATOR NAME: YaTing YangTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3