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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802266
Report Date: 11/04/2022
Date Signed: 11/04/2022 03:33:18 PM


Document Has Been Signed on 11/04/2022 03:33 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:BELLA VITA ASSISTED LIVINGFACILITY NUMBER:
405802266
ADMINISTRATOR:TESFAZGY, ABIYFACILITY TYPE:
740
ADDRESS:7150 SYCAMORE ROADTELEPHONE:
(805) 460-6883
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 4DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Staff #1 and Abiy Tesfazgy, Licensee/AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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On 11/04/22 at 1:55 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Staff #1 (S1) at the facility and spoke with by phone Abiy Tesfazgy, Licensee/Administrator, and explained the purpose of the visit.

LPA toured the facility with S1 and observed the following: The facility has infection control signage throughout the facility on handwashing, cough etiquette and use of masks. The facility is missing infection control signage at the front door. Licensee will post COVID information and visitor policy at the front door, take a photo, and send to LPA by 11/7/22. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (2). Fire extinguishers are located in the kitchen and dining room. The dining room extinguisher is fully charged and was inspected on 12/27/21. The kitchen fire extinguisher is fully charged, however, it does not have an inspection tag on it. Licensee says it was purchased on 12/25/21. Licensee will attach the receipt to the fire extinguisher, take a photo, and send to LPA by 11/11/22. The facility’s north gate is missing a self-closing mechanism. Licensee will install a mechanism, take a video, and send to LPA by 11/11/22. The facility has a 11”x14” CDSS complaint poster. This should be 20”x26”. Licensee says he has the poster. Licensee will display in a common area, take a photo, and send to LPA by 11/11/22. At 2:10 pm, LPA observed a gallon container of bleach and all-purpose cleaner, and eight smaller containers of cleaning chemicals in the unlocked garage. Deficiency cited on a 9099-D page.

At 2:23 pm, LPA conducted the Infection Control mitigation module by phone with the licensee. LPA discussed items to be corrected and deficiency with licensee.

Exit interview conducted, deficiency cited and report and appeal rights emailed to the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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 2


Document Has Been Signed on 11/04/2022 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BELLA VITA ASSISTED LIVING
FACILITY NUMBER: 405802266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia. 87705 Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2)... toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations of a gallon container of bleach and all-purpose cleaner, and eight smaller containers of cleaning chemicals in the unlocked garage, the facility did not meet the requirements of the above regulations..
POC Due Date: 11/07/2022
Plan of Correction
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Staff immediately placed the chemicals in a locked cabinet in the laundry room. Licensee will conduct staff training on ensuring that dangerous items are inaccessible to all residents in care. Licensee will ensure chemicals are in a permanent locked area inaccessible to residents. Licensee will provide proof of staff training to LPA by 11/07/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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