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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602253
Report Date: 10/13/2021
Date Signed: 10/14/2021 06:23:35 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2021 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20211007125727
FACILITY NAME:BELLA VISTA AT LINCOLNFACILITY NUMBER:
198602253
ADMINISTRATOR:HAMILTON, MARKFACILITY TYPE:
735
ADDRESS:2612 N LINCOLN AVETELEPHONE:
(626) 794-4103
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:50CENSUS: 39DATE:
10/13/2021
UNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Amada Lopez, ManagerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff member pushed resident to the ground.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Rosaura Valenzuela and Abeye Duguma conducted an unannounced complaint investigation for the above noted allegation. LPAs met with Amada Lopez, Manager. The purpose of the visit was discussed.

It was reported that facility staff #1 (S1) pushed resident #1 (R1) to the ground. During the investigation on 10/13/2021 at 4:20pm, LPA Valenzuela spoke to facility staff that had knowledge of the incident. Interviews revealed R1 was the assailant and that S1 was the victim. It was alleged that R1 was sitting on a freezer chest on 05/27/2020 and that when S1 asked R1 to move and R1 refused to move S1 forcefully removed R1 from the top of the chest. S1 denies touching R1. R1 was arrested after the altercation.

At 4:30pm, LPA obtained facility notes pertaining to R1. Documents revealed that R1 had a history of putting their hands on staff and of threatening to harm them.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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 2
Control Number 31-AS-20211007125727
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLA VISTA AT LINCOLN
FACILITY NUMBER: 198602253
VISIT DATE: 10/13/2021
NARRATIVE
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Based on interviews and record review, it has been determined that this allegation is UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2