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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801891
Report Date: 05/26/2021
Date Signed: 05/26/2021 04:44:17 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:
05/26/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Esther PenaflorTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Walters conducted an unannounced POC visit to follow up on deficiencies cited on 5/18/21. At the time of inspection there were three staff providing care and supervision for five residents.

During previous visit LPA observed resident (R1's) belongings and bed in a room that does not meet the licensing standards and that was not approved by the fire department for residents. Based on the facility sketch, there were four bedrooms approved by the fire department that were to be used by residents. Staff S1 was residing in resident bedroom 2. R1 was residing in a staff room that was not designated as a living quarter. During previous visit LPA advised that the Administrator move resident R1 into a room that was designated for residents. LPA explained that evicting R1 or increasing their rent would be a personal rights violation. Administrator stated that they understood that all of S1's items were to be removed from bedroom 2.

During today's visit, LPA toured the facility and observed that S1's belongings were still in bedroom 2. Administrator stated it would be to difficult to remove all of S1's items from bedroom 2 and that they agreed with the family to relocate R1 to their responsible parties home until they build another room.

An immediate civil penalty for $500.00 was issued today for placing a resident in a room that was not designated for residents. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. This report was read and discussed with Esther Penaflor Appeal rights were provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2021
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations.. by the State Fire Marshal for the protection of life and property against fire and panic. Based on LPAs observation the facility failed to be in conformity
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by placing resident R1 in a room that was not approved by the fire department for residents, which poses an immediate health and safety risk to residents in care.
**Immediate Civil Penalty assessed in the amount of $500.
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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: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021
LIC809 (FAS) - (06/04)
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