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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802266
Report Date: 10/17/2024
Date Signed: 10/17/2024 10:53:40 AM


Document Has Been Signed on 10/17/2024 10:53 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
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:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Licensee Abiy TesfazgyTIME COMPLETED:
11:55 AM
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At 8:30 am on 10/17/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual inspection visit. LPA met with Licensee Abiy Tesfazgy, announced who he was and the reason for the visit.
LPA toured facility to note the facility is maintained in conformance with state fire marshal regulations. smoke detectors and carbon monoxide detectors functioning throughout the facility. Fire extinguisher was fully charged. This facility has a water sprinkler system in its roof and water pressure tested in December 23, of 2023 by Atascadero Fire Safety. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 72 *(f). Hot water temperature tested and read within regulation parameters. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed two days of perishable and seven days of non-perishable food. A written disaster and mass casualty plan is readily available located on the kitchen wall. Medications are stored in a locked cabinet in the kitchen. LPA reviewed resident and staff files. LPA noted that this a 4 bed room and two bathroom facility with two rooms for double resident occupancy and two rooms for single resident occupancy. LPA noted that there are two living rooms, a dining room and kitchen.There is a covered patio in the back that is screened to provide residents shade for outside activities. LPA noted that the laundry room did not have a door and the locked cabinet on the right side of the laundry room was not functioning and chemicals were readily accessible to residents in care.
Licensee and LPA conduced a full review of the care tools module. LPA noted that Community Care Licensing (CCL) regulation 87309(a) was cited as noted in report above in the care tools modules. LPA noted that no other citations, violations, technical were issued in this full annual inspection.

Exit interview, report read, appeal rights, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
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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