486801891-3-30-2021-21-AS-KMOA-BZNRPZ-20210401131244

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486801891
Report Date: 03/30/2021
Date Signed: 03/30/2021 04:24:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2020 and conducted by Evaluator Karina Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200813141337

FACILITY NAME:	BELLA VISTA RESIDENTIAL CARE FACILITY FOR ELDERLY		FACILITY NUMBER:	486801891
ADMINISTRATOR:	PENAFLOR, ESTHER		FACILITY TYPE:	740
ADDRESS:	804 BELLA VISTA DRIVE		TELEPHONE:	(707) 301-5300
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 4	DATE:	03/30/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Esther Penaflor, Licensee		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Unlawful Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) K. Canela contacted Esther Penaflor, Licensee and Administrator at Bella Vista Residential Care Facility for the Elderly, on 03/30/2021 by phone for the purpose of delivering findings on complaint # 21-AS-20200813141337. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.

During the investigation, LPA conducted interviews, requested and reviewed documents, as well as the facility file.

Report continued on LIC9099-C

Signatures in file

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20200813141337

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BELLA VISTA RESIDENTIAL CARE FACILITY FOR ELDERLY	FACILITY NUMBER: 486801891
	VISIT DATE: 03/30/2021

NARRATIVE

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Complaint alleges the Licensee refused to accept Resident (R1) back to the facility after being discharged from North Bay Medical Center. R1 was admitted to the emergency room twice on 08/08/2020 due initially to uncontrolled pain and subsequently for aggression. R1 was medically cleared for discharge on 08/08/2020. It was alleged the facility refused to accept R1 due to R1’s “aggression”. R1 was sent back to the facility with resources from North Bay Medical Center for optional placement. Additional statements alleged the facility initiated the eviction by packing R1’s belongings before R1 was discharged from the hospital. Licensee stated they did not issue or initiate an eviction. The licensee stated they did pack R1’s belongings to assist R1, since they were physically unable and per request of R1's responsible party . The Licensee stated R1’s responsible party had stated over the phone to Licensee that they previously planned to remove R1 from the facility to live at home.

Due to contradicting statements, as well as all the information gathered with other related parties, The Department was not able to corroborate the allegation. Although the allegation of an “unlawful eviction” may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Esther Penaflor, Licensee, whose signature on this form confirms receipt of these documents.

Signatures in file

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

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