405850007-3-18-2024-29-AS-RDLN-D3H2FR-20240318172159

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850007
Report Date: 03/18/2024
Date Signed: 03/18/2024 05:22:51 PM

Document Has Been Signed on 03/18/2024 05:22 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:	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:	03/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Gabriela Soo, Licensee		TIME COMPLETED:	05:35 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 12:00pm 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, hand soap, and hand washing signs. 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 and the use of Personal Protective Equipment (PPE). 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 fenced 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. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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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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: 03/18/2024

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 01/29/2025. 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 7 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.

Personnel Records & Training: The facility keeps trianing records for each staff member. Staff are in process of completing training on all subjects/topics and hours for 2024.

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.

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

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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: 03/18/2024

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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 residents medications, no labels were altered, and no medications were expired. 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 destroy 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 conducts quarterly disaster drills. The fire extinguishers was charged and purchase annually with a receipt for purchase of 02/2024. 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 has 1 gate in need of repair due to normal wear and tear so it can self latch again. The facility currently has no residents on oxygen. The facility currently has 3 hospice residents in care. The facility currently has no residents receiving Home Health services. Hospice 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.

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

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/18/2024 05:22 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 SENIOR LIVING	FACILITY NUMBER: 405850007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in 4 out of 4 staff are in the process of completing annaul trianing which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2024
	Plan of Correction
1 2 3 4	Licnesee/Administrator will complete 20 plus hours of annual trianing with all staff and send proof of trianing to CCL.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above Facility did not have records of any quarterly drills for 2023/2024 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will have a quarterly fire and earthquake drills completed and send proof to CCL.

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

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