197608297-5-5-2023-28-AS-FFIS-CY3Q39-20231130104819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608297
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:15:41 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
04/25/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230425091406

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: 34	DATE:	05/05/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator -Ian Baker		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff did not ensure that resident received adequate showers while in care.
Facility staff did not ensure that resident was adequately fed while in care.
Facility staff did not ensure that resident's room was cleaned while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint visit to investigate the allegations listed above. LPA met with Administrator, Ian Baker and explained the reason for the visit.

The investigation consisted of the following: LPA Calderon alongside with Baker toured the two story facility, kitchen, dining area, residents rooms #7,8, 9,11, 12, 16,17,18 22, 25, and 33 and observed (6) six common shower rooms. LPA Calderon observed AM snack time and lunch. Interviews were conducted with Ian Baker, Staff #1-3. LPA Interview Residents #1, #2, #3 and #4 (R1 -R4) LPA reviewed and obtained a resident and staff roster. LPA reviewed Resident #1’s (R1) records: Special Incident Reports, Pre Placement Appraisal, Needs and Service Plan, Three Doctor Notes, Inventory List, Weight Chart, and Discharge Document.

Continuation on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230425091406

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: 05/05/2023

NARRATIVE

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In regards to allegation: Facility staff did not ensure that resident received adequate showers while in care. LPA Calderon interview with staff Ian Baker, S1-S3 all denied the above allegation stated R1 was able to shower on their own and resident's who need assistance are being provided showers. Interview with residents: R1 denied the above allegation and stated they were responsible in taking their own showers and preferred showering once a week. R3 and R4 denied above allegation and stated showers are being provided and staff assist residents with showers for those who need assistance. LPA Calderon observed functioning and clean showers throughout the second story, a total of six common showers. LPA reviewed R1's Pre-Placement Appraisal and Needs and Service Plan which states R1 is independent and can perform all activities of daily living independently and does not need help with bathing.

In regards to allegation: Facility staff did not ensure that resident was adequately fed while in care. LPA interviews with staff Ian Baker, S1-S3 all denied the above allegation stated residents are encouraged to eat their food and there are food replacements if needed. Interview with residents: R1 denied the above allegation and stated they provided food but the food served wasn't their preference. R3 and R4 denied the above allegation and stated they are provided food. R3 stated meal replacement is provided when asked.
LPA reviewed R1's Pre-Placement Appraisal and Needs and Service Plan which states R1 is independent and can perform all activities of daily living independently and does not need assistance with eating. LPA observed staff going around the hallway and to each residents room door letting residents know meals are ready and encouraging them to go to the dinning room for snack time and lunch time. LPA observed adequate perishable and non perishable food items in the kitchen.

In regards to allegation: Facility staff did not ensure that resident's room was cleaned while in care. LPA interview with staff Ian Baker, S1-S3 all denied the above allegation stated residents rooms are cleaned daily. LPA interviews with residents: R1 denied the above allegation and stated staff would clean their room. R3 and R4 denied the above allegation and stated rooms are cleaned every day. LPA toured residents room's and common areas and observed clean rooms, house keepers cleaning, facility appeared in clean and sanitary condition for residents in care.

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 with Administrator Ian Baker and a copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

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