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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602253
Report Date: 08/17/2024
Date Signed: 08/19/2024 09:05:55 AM

Document Has Been Signed on 08/19/2024 09:05 AM - 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELLA VISTA AT LINCOLNFACILITY NUMBER:
198602253
ADMINISTRATOR/
DIRECTOR:		HAMILTON, MARKFACILITY TYPE:
735
ADDRESS:2612 N LINCOLN AVETELEPHONE:
(626) 798-9118
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 50CENSUS: 33DATE:
08/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Amada Lopez, Supervisor TIME VISIT/
INSPECTION COMPLETED:
03:00 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-Ettima and Gary Tan conducted an unannounced required visit to the facility. LPAs met with Resident Care Specialist, Colin Jones and explained the reason for the visit. At 9:56AM Supervisor, Amada Lopez arred and joined us. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today.

A tour of the physical plant was conducted at 10:20AM with Supervisor 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 six (6) bathrooms currently occupying ten (10) female residents. There is no staff room. The facility maintains a comfortable temperature at 79°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 purchased on 08/17/2024. 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. LPAs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored in the laundry room and basement. Sharp objects are stored and locked in a drawer in the kitchen. 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: LPAs 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLA VISTA AT LINCOLN
FACILITY NUMBER: 198602253
VISIT DATE: 08/17/2024
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
 Medications: LPAs observed medications to be locked placed in a cabinet and inaccessible to resident. All residents medications were delivered from the pharmacy in the bubble packs. Randomly selected residents medication was reviewed and appeared to meet Title 22 Requirements. There was three (3) complete first aid kit in medication room located in the main building adjacent to the main office. The garage was converted into a laundry area which 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.
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 that is not used. Currently occupying one (1) male resident. 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 purchased on 08/17/2024. 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: LPAs observed bathroom to be clean, properly supplied and had functional fixtures. LPAs 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. Fire extinguishers were fully charged and last purchased on 08/17/2024.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: LPAs observed all bathrooms to be clean, properly supplied and had functional fixtures. LPAs observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amount 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
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLA VISTA AT LINCOLN
FACILITY NUMBER: 198602253
VISIT DATE: 08/17/2024
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
bedrooms.Fire extinguishers were fully charged and last purchased on 08/17/2024. 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: LPAs 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/TV 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 six (6) female residents.
The facility maintains a comfortable temperature at 77°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 purchased on 08/17/2024. 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: LPAs 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.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: LPAs conducted a file review at 1:00PM 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, appraisal 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-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3