405850007-3-21-2025-29-AS-RDLN-DEYU5U-20250321151720

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850007
Report Date: 03/21/2025
Date Signed: 03/21/2025 03:17:40 PM

Document Has Been Signed on 03/21/2025 03:17 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 SENIOR LIVING		FACILITY NUMBER:	405850007
ADMINISTRATOR/ DIRECTOR:	BUDAI, KAROLY		FACILITY TYPE:	740
ADDRESS:	145 ANDRE DRIVE		TELEPHONE:	(310) 500-6461
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY: 6		CENSUS: 6	DATE:	03/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Licensee Gabriela Soo		TIME VISIT/ INSPECTION COMPLETED:	03:25 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 Analyst (LPA) De Leon arrived at 10:00am to conducted a 1 year annual visit to the facility above. LPA met with Licensee Gabriela Soo and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binders for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control, the use of Personal Protective Equipment (PPE) and universal precautions. Physical Plant & Environment Safety: The facility is a 4 bedroom and 4 bathrooms currently occupying 6 resident and employs 2 full time staff, 1 back up staff and 2 Administrators. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The kitchen is clean, safe and sanitary. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in garage or storage closet. The facility has sufficient space inside and outside for activities and visiting. The facility has an a backyard for resident use with plenty of shade. The facility has telephone and internet service for resident use. Laundry room and garage are kept locked. Facility has a working washer and dryer present. The facility has 3 ponds 2 ponds have river rock in them so the water is not deep in either, 1 pond currently has not water present. The facility has two fountains a small one on the side of the house and it is filled with rocks, one fountain in by the front entry door, it is large and currently not in use, if the facility starts to use it again LPA recommended river rock in the bottom tier so it would not be deep if not going to use put plants in it so it does not feel with water if it rains. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA VITA SENIOR LIVING	FACILITY NUMBER: 405850007
	VISIT DATE: 03/21/2025

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 01/29/2026. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory/Bedridden. Hospice is approved for 4.

Staffing: The facility currently employes 2 full time staff, 1 backup additional staff and 2 Administrators. Licensee has two facilities and employs 6 staff that can be used for back up staffing at facilities if needed, Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrators certificates are expired all documents have been submitted for renewal. Administrator will follow up with renewal.

Personnel Records & Training: The facility keeps training records for each staff member. Staff have completed 20 plus hours of annual training from 04/2024-03/2025. Training records are kept confidential in a staff training binder with staff records.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible and records are kept confidential. Residents have current appointment for updating medical assessments for the 2025 calendar year.

Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices.
Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA VITA SENIOR LIVING	FACILITY NUMBER: 405850007
	VISIT DATE: 03/21/2025

NARRATIVE

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Incidental Medical Services: Facility provides transportation or assist in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed all residents medications, no labels were altered, no medications were expired and all medications were kept in original containers. All forms were completed accurately.
Administrator and 1 staff person review medications for destruction, complete forms and take to the pharmacy to be destroyed or destroyed on cite. Medications are kept in a locked cupboard in the kitchen.

Disaster Preparedness: The current emergency disaster forms were posted. The facility needs to documents quarterly disaster drills as regular training records. The fire extinguishers was charged and purchase annually with a receipt for purchase of 5/08/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility gates are self closing and self latching and has some fencing around the property back yard area. The facility currently has no residents on oxygen. The facility currently has 4 hospice residents in care. The facility currently has 1 resident receiving Home Health services. Hospice and Home Health plans are kept on file and up to date. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working and alarmed properly when door was opened and closed.

Exit interview conducted, copy of report and appeal rights printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC809 (FAS) - (06/04)

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