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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801891
Report Date: 05/22/2023
Date Signed: 05/22/2023 08:06:08 PM


Document Has Been Signed on 05/22/2023 08:06 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: 4DATE:
05/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Esther PenaflorTIME COMPLETED:
03:53 PM
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced to conduct a Required- 1 Year, annual inspection and was greeted by Administrator, Esther Penaflor. This facility is licensed for 6 non-ambulatory residents and has an approval for 3 of the residents to receive Hospice services. LPA will correct and issue a new license to reflect the Hospice waiver for 3 residents that was previously approved for this facility.

LPA began tour and inspection of the building and grounds which was found to be clean and a comfortable temperature, with all exits free from obstruction.
Toxins were secured in a locked cabinet in the kitchen. Smoke detectors and Carbon Monoxide detectors were operational. Fire Extinguishers were last serviced 01/9/2023. There are auditory alerts on exit doors. Water temperature was 107 degrees f. and within the required range of 105 to 120 degrees Fahrenheit. Bathrooms have required non-skid surfaces and grab bars. Resident bedrooms are furnished per regulation. Cleaning products are stored locked. The Knives are stored and locked in the kitchen. There is adequate space and furniture for activities. There was more than a 7 day supply of non-perishable foods that were stored properly and appeared in good condition. The pantry contained plenty of food. There is a locked cabinet for residents' medications. Staff and resident files are locked in the office.
All 4 resident files were reviewed and found in compliance. Staff files contained the required training and CPR/1st aid expired 3/11/2025. Administrator certificate for Esther Penaflor #6014044740 is current and expires 5/8/2024.
LPA went over annual required training for all staff.

Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELLA VISTA RESIDENTIAL CARE FACILITY FOR ELDERLY
FACILITY NUMBER: 486801891
VISIT DATE: 05/22/2023
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LPA and Administrator discussed: Facility to submit an updated facility Sketch one for the inside of the facility and one for the facility yard. Facility to update and identify rooms that will be used by residents and rooms that will be used by staff. LPA also went over the sliding door for resident R1 and R2 and will need to make sure the door opens easily as the weather may have affected the door from having a smooth sliding mechanism.


LPA requested the following updated forms:

· Copy of Administrator Certificate
· LIC 308 Designation of responsibility
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property and Liability insurance

· Infection Control Plan of Operation (If changes)



No deficiencies cited during today's visit. Exit interview conducted.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
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