198602253-9-28-2023-31-AS-AALR-CW524X-20230928170441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602253
Report Date: 09/28/2023
Date Signed: 09/28/2023 05:05:00 PM

Document Has Been Signed on 09/28/2023 05:05 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BELLA VISTA AT LINCOLN		FACILITY NUMBER:	198602253
ADMINISTRATOR:	HAMILTON, MARK		FACILITY TYPE:	735
ADDRESS:	2612 N LINCOLN AVE		TELEPHONE:	(626) 798-9118
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY: 50		CENSUS: 34	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:			TIME COMPLETED:	05:15 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) Antonia Alvizar and Rosaura Valenzuela conducted an unannounced required annual visit to the facility. LPA's met with Supervisor Amada Lopez and explained the reason for the visit. At 12:03PM Administrator, Kim R. Commodore arrived and joined us. LPA Alvizar utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: A tour of the physical plant was conducted at 10:40AM with Amanda for compliance with safety, maintenance and operational requirements. The following was noted: Main Building: There is one main entrance at the facility and there are required posters posted at the main door. Facility is a single story residence and consists of eight (8) bedrooms and four (4) bathrooms currently occupying nine (9) female residents. There is no staff room. The facility maintains a comfortable temperature at 75°F. The smoke detectors and Carbon Monoxide detectors were tested and function properly. Fire extinguishers are located in the common areas and at the end of the hallway near the bedrooms. Fire extinguishers were fully charged and last serviced on 06/19/2023. Cleaning supplies and toxic substances are inaccessible to residents. Kitchen: The kitchen appeared to be clean and the appliances and fixtures functional. This kitchen is used to prepare and cook all meals for residents in care. LPA's observed a sufficient amount of perishable and non-perishable food at the facility; properly stored in the garage and basement. Sharp objects are stored and locked in a drawer in the kitchen. Medications are placed in a locked cabinet located next to the administrator office. Bedrooms: The resident bedrooms were properly furnished. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA VISTA AT LINCOLN	FACILITY NUMBER: 198602253
	VISIT DATE: 09/28/2023

NARRATIVE

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Bathrooms: LPA's observed all bathrooms to be clean, properly supplied and had functional fixtures. LPA's observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured and was within required title 22 regulations.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair.

Annex A:
Facility is a single story residence and consists of; five (5) bedrooms, three (3) bathrooms one (1) recreation room and one (1) Hall. Currently occupying eight (8) male residents. The facility maintains a comfortable temperature at 75°F. The smoke detectors and Carbon Monoxide detectors were tested and function properly. Fire extinguishers are located in the common area and at the end of the hallway near the bedrooms. Fire extinguishers were fully charged and last serviced in 06/19/2023. Cleaning supplies and toxic substances are inaccessible to residents.

Bedrooms: The resident bedrooms were properly furnished. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: LPA's observed all bathrooms to be clean, properly supplied and had functional fixtures. LPA's observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured within title 22 regulations.

Common Areas: These included the recreation room and hall. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair.

Lincoln House:
Facility is a single story residence and consists of; four (4) bedrooms, three (3) bathrooms, a living room, a dining room, and a hall. Currently occupying eight (8) female residents.

The facility maintains a comfortable temperature at 75°F. The smoke detectors and Carbon Monoxide detectors were tested and function properly. Fire extinguishers are located in the common area and at the end of the hallway near the bedroom. Fire extinguishers were fully charged and last serviced on 06/19/2023. Cleaning supplies and toxic substances are inaccessible to residents.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA VISTA AT LINCOLN	FACILITY NUMBER: 198602253
	VISIT DATE: 09/28/2023

NARRATIVE

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Bedrooms: The resident bedrooms were properly furnished. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: LPA's observed all bathrooms to be clean, properly supplied and had functional fixtures. LPA's observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured within requirement of title 22 regulations.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair.

Ventura House:
Facility is a single story residence and consists of; three (3) bedrooms, one (1) bathroom, activity room, a screened porch, a dinette and kitchen is not used. Currently occupying two (2) male residents. The facility maintains a comfortable temperature at 75°F. The smoke detectors and Carbon Monoxide detectors were tested and function properly. Fire extinguishers are located in the common area and at the end of the hallway near the bedrooms. Fire extinguishers were fully charged and last serviced on 06/19/2023. Cleaning supplies and toxic substances are inaccessible to residents.

Bedrooms: The resident bedrooms were properly furnished. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathroom: LPA's observed bathroom to be clean, properly supplied and had functional fixtures. LPA's observed grab bars and non-skid mats in bathroom. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured within title 22 regulations.

Common Areas: These included the activity room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair.

Annex B:
Facility is a single story residence and consists of; five (5) bedrooms, two (2) bathrooms, and a hall. Currently occupying eight (8) male residents.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA VISTA AT LINCOLN	FACILITY NUMBER: 198602253
	VISIT DATE: 09/28/2023

NARRATIVE

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The facility maintains a comfortable temperature at 75°F. The smoke detectors and Carbon Monoxide detectors were tested and function properly. Fire extinguishers are located in the common area and at the end of the hallway near the bedrooms. Fire extinguishers were fully charged and last serviced on 06/19/2023. Cleaning supplies and toxic substances are inaccessible to residents.

Bedrooms: The resident bedrooms were properly furnished. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: LPA's observed all bathrooms to be clean, properly supplied and had functional fixtures. LPA's observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured within title 22 regulations.

The Garage is located between Annex A and Annex B were linens and perishable food are stored and all laundry is done, laundry detergents, cleaning agents and other toxins are stored in a locked cabinet.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

File Reviews: Also, during today's visit, LPA Valenzuela conducted a file review at 12:10PM for residents and staff regularly scheduled. Staff have current first aid and training documentation showing required training completed. Resident records were observed complete. All residents have current annual physician’s report, appraisals and admission agreements on file.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, no deficiencies were observed/cited. Exit Interview Conducted and a Copy of the Report was Issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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