<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801891
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:01:35 PM


Document Has Been Signed on 03/29/2022 12:01 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 5DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Esther Penaflor, Administrator TIME COMPLETED:
12:15 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), Walters arrived unannounced to conduct a Required- 1 Year, annual visit and was greeted by Administrator, Esther Penaflor. This 1-year annual visit will focus on the inspection control of this facility. The facility submitted an infection control mitigation plan which was approved by Community Care Licensing on 12/28/21.

At approximately 9:50 AM, LPA began tour and inspection of the building and grounds which was found to be clean and a comfortable temperature. At the entrance of the facility there is a sign sheet for visitors, with hand sanitizer and disposable mask. Facility has an additional 30 day supply of incontinence product's and Personal Protective Equipment which include: N95 mask, gowns, gloves and face shields. Restrooms were stocked with liquid soap and paper towel. Medication was centrally stored. Toxins were secured in a locked cabinet in the kitchen. Smoke detectors and Carbon Monoxide detectors were tested and appeared to be in working order. Fire Extinguishers were last serviced 01/17/2022.

LPA reviewed resident and staff records. Staff and Resident vaccine cards were on file. All residents and staff have been vaccinated. Administrator was unable to provide LPA with staff's infection control training. Administrator stated that all staff are scheduled for PPE and infection control training on 4/8/22. LPA is requesting that facility submits a copy of staff training performed, training to include topics, staff signatures and dates by 4/15/22.

LPA and Administrator discussed: Adding additional signs throughout the facility to promote social distancing and promote hand washing and, Documenting all staff training's.

There no deficiencies cited during today's visit. Exit interview conducted.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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 1