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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802266
Report Date: 11/06/2023
Date Signed: 11/06/2023 02:01:15 PM


Document Has Been Signed on 11/06/2023 02:01 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: 5DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Direct Care Staff TIME COMPLETED:
02:00 PM
NARRATIVE
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 At 9:30 am on 11/06/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual inspection visit. LPA met with direct care staff Jackie Tatsuo (S1), announced who he was and the reason for the visit. S2 called Licensee Abiy Teafazgy by phone, Licensee was out of town shopping for facility grocery's and gave verbal permission to LPA to conduct annual visit with S1.
LPA toured facility with S1. 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 wes pressure tested in December of 2022 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. LPA reviewed resident and staff files. LPA discovered that 4 of 5 residents have been identified with a diagnosis of Dementia by prior Physician reports (LIC602's) and/or Appraisals Needs and Services Plans whose Physicians reports are over 12 months since last LIC602 was completed. LPA addressed those deficiencies in annual care tools specific to those violations. LPA noted that the facility was clean and in good repair.
LPA conducted a full annual care tools review. LPA noted and cited on 4 residents not having a current LIC602 according to their individual diagnosis. LPA contacted the Licensee by phone and addressed the violation with a plan of correction on this citation. LPA noted that no other citations, violations, technical were issued in this full annual inspection.
Exit interview, report read to S1 and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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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Document Has Been Signed on 11/06/2023 02:01 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: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(b)(5)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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