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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801891
Report Date: 05/09/2024
Date Signed: 05/09/2024 03:15:51 PM


Document Has Been Signed on 05/09/2024 03:15 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
SANTA ROSA RO, 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:
7073015300
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 3DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Esther Pena Flor, AdministratorTIME COMPLETED:
01:15 PM
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At approximately 10:15 AM, Licensing Program Analyst (LPA) Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by and met with Esther Pena Flor, Administrator. At approximately 10:20 AM, LPA and administrator toured the building and grounds which was found to be clean and in good repair.

All notices that are required to be posted have been posted and are in a highly visible area. LPA observed . one resident in the living room listening to music and two residents in bed by choice as the residents are nocturnal and stay up until about 2 AM waking up around 11:30 AM . The amount of perishable and nonperishable foods is with in regulation. LPA advised administrator to ensure all food is checked for expiration and all food kept must be fresh and within the expiration date. Water temperature did measure within regulation between 113.9 and 114.1 degrees F at two of three faucets accessible to residents. Facility backyard has patio furniture and covering allowing the residents to enjoy the outdoors. Three out of three fire extinguishers inspected were charged. Smoke detectors/carbon monoxide detectors inspected and were found to be in working order. Facility temperature was within regulation at 74 degrees F. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

At approximately 11:10 AM, LPA reviewed 3 of 3 resident records and found all files current and up to date. Medication records are thorough.

At approximately 12:00 PM, LPA reviewed 2 of 2 staff records.2 of 2 records did not contain signed SOC341A Advised licensee/administrator all staff must sign SOC341A by date of 05/10/2024. Administrator Esther Pena signed on site and provided proof of Administrator Certificate submission and payment made on 05/01/2024. Evidence of first aid and CPR training were current.

Continued on 809C.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie MutialuTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELLA VISTA RESIDENTIAL CARE FACILITY FOR ELDERLY
FACILITY NUMBER: 486801891
VISIT DATE: 05/09/2024
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Continued from 809

At approximately 12:45 PM, LPA reviewed the facility emergency disaster plan with staff. Facility has flashlights and portable gas burner during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 04/03/2024 for both day and night shifts.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
Evidence of Liability Insurance
LIC610E- Disaster Plan



No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie MutialuTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3