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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801891
Report Date: 05/18/2021
Date Signed: 05/18/2021 05:05:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 ELDERLYFACILITY NUMBER:
486801891
ADMINISTRATOR:PENAFLOR, ESTHERFACILITY TYPE:
740
ADDRESS:804 BELLA VISTA DRIVETELEPHONE:
(707) 301-5300
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Esther PenaflorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Annual Required – 1 yr. Infection Control inspection at this facility and met with Administrator, Esther Penaflor. At the time of inspection, there were two staff providing care and supervision for six residents.

LPA arrived at the facility and observed the facility had proper signage. There was a sanitization station at the entrance of the facility, along with a sign-in binder for visitors and temperature gun. The facility was a comfortable temperature of 74. LPA observed that staff were wearing face masks. Residents were socially distanced in the living room. Other residents were resting in their room. Per Administrator, resident are monitored for symptoms daily. Resident emergency contact information has been updated and Emergency Personnel numbers are posted in the facility hallway. Residents’ medications are stored and locked in the hallway cabinets. Facility has a 30-day supply of medication for clients. Facility has submitted a mitigation program plan, LPA is requesting that some modifications be made to the mitigation plan and sent to CCL. Postings pertaining to COVID-19 were throughout the facility. Facility has PPE supply stored in a closet in the laundry room and garage.

During today’s visit LPA observed that the following wasn't in compliance:


At 9:33 AM LPA observed resident (R1's) belongs and bed in staff room that was not approved by the fire department for residents. Administrator was present. Facility sketch confirms that this room was approved as a staff room. Administrator EP stated that they were unaware that resident couldn't sleep in the staff room.

California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC- 809D. Exit interview conducted with Esther Penaflor, Appeal Rights provided. Administrator declined to sign. LPA sent copy by email.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BELLA VISTA RESIDENTIAL CARE FACILITY FOR ELDERLY
FACILITY NUMBER: 486801891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and review of facility sketch,the licensee did not comply with the section cited above in 1 out of 4 residents were living/sleeping in a room that is designated for staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2021
Plan of Correction
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Administrator agrees to submit a picture identifying that Resident R1’s room has been placed in a room designated for residents. In addition, Administrator is to update facility sketch to include the size and inividuals allowed in each room to CCL Rohnert Park attention LPA Katrina Walters by POC due date 5/19/21.
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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2021
LIC809 (FAS) - (06/04)
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