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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602253
Report Date: 10/20/2022
Date Signed: 10/20/2022 01:42:53 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, 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
09/29/2022 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20220929103403
FACILITY NAME:BELLA VISTA AT LINCOLNFACILITY NUMBER:
198602253
ADMINISTRATOR:HAMILTON, MARKFACILITY TYPE:
735
ADDRESS:2612 N LINCOLN AVETELEPHONE:
(626) 798-9118
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:50CENSUS: 38DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Amada Lopez, ManagerTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff are overmedicating resident in care.

Staff yell at resident while in care.

Staff are threatening resident in care.

Staff do not treat resident with dignity and respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent visit to deliver the findings for the above noted allegations. LPA met with Amada Lopez, Manager. The purpose of the visit was discussed.

It was reported that staff are overmedicating resident in care. To investigate this allegation, on 10/03/2022 between 1:05pm and 1:40pm, LPA initiated staff interviews. Staff interviews revealed that facility is following the doctor's orders and is giving Resident #1 (R1) their medication as prescribed. On 9/30/2022, LPA interviewed R1. Interviews revealed that R1 had not seen their doctor in several months. R1 also said that they had not addressed their medication concerns with their doctor. On 10/03/2022 at 1:45pm, LPA reviewed R1's Medication Administration Record (MAR). Records confirmed that facility is giving R1 medication as prescribed by the physician.

See 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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 2
Control Number 31-AS-20220929103403
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: 10/20/2022
NARRATIVE
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Based on interviews and records review, there is not sufficient information to support this allegation. Thus, this allegation is deemed UNSUBSTANTIATED at this time.

It was alleged that staff yell at resident while in care, To investigate this allegation, LPA Valenzuela on 10/03/2022, between 1:05pm and 1:40pm, initiated staff interviews. Staff interviews revealed that it is R1 that yells at staff. Staff deny yelling at R1 or at any of the residents. On 10/03/2022 at 1:45pm, LPA reviewed facility records. Records confirmed what was reported to LPA by staff.

Based on interviews and records review, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time.

It was reported that staff are threatening resident in care. On 10/03/2022 between 1:05pm and 1:40pm, staff interviews were initiated. Interviews revealed that it is R1 who is threatening staff. According to staff, R1 makes death threats against them. Staff deny making threats to R1. On 10/03/2022 at 1:45pm, LPA reviewed facility records. Records confirmed what staff told LPA.

Based on interviews and records review, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time.

It was alleged that staff do not treat resident with dignity and respect. To investigate this allegation, LPA on 10/03/2022, between 1:05pm and 1:40pm, initiated staff interviews. Interviews revealed that it is R1 who does not treat staff with dignity and respect. Staff deny not treating resident with dignity and respect. On 10/03/2022 at 1:45pm, LPA reviewed facility records. Records confirmed what staff had reported to LPA.

Based on interviews and records review, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2