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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803536
Report Date: 02/11/2022
Date Signed: 02/11/2022 12:17:31 PM


Document Has Been Signed on 02/11/2022 12:17 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 VILLAGEFACILITY NUMBER:
496803536
ADMINISTRATOR:VEGVARY, JULIUSFACILITY TYPE:
740
ADDRESS:18941 SONOMA HWYTELEPHONE:
(707) 483-0998
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:12CENSUS: 7DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Licensee, Mercedes VegvaryTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 11:05 AM, and met with licensee Mercedes Vegvary. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. LPA observed staff with record book of visitor, staff, and resident screenings. LPA conducted walk through of the facility with licensee and observed COVID postings throughout. Mitigation plan was submitted by licensee and reviewed by Community Care Licensing.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per licensee, updated infection control guidelines and PINs are communicated to responsible parties verbally. Staff have completed Personal Protective Equipment (PPE) and infection control training through a Kaiser nurse. Staff have been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census residents could isolate in their own rooms if they became ill. LPA observed necessary PPE to support a resident in isolation. Residents are screened twice a day for symptoms.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents in locked cleaning closets. Medications are centrally stored and inaccessible to residents in admin office. Facility is conducting COVID-19 surveillance testing per CCL guidelines. All residents have received their booster shot. 3 Staff have received boosters and 2 are testing weekly.

Continued on LIC 809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2022
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 VILLAGE
FACILITY NUMBER: 496803536
VISIT DATE: 02/11/2022
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. Visitiation is preferred indoors but it is being allowed indoors.

LPA requested the following documents during the visit:

LIC 500
LIC 308
Liability Insurance
Emergency Disaster Plan

No deficiencies cited during this inspection.

Exit interview conducted with licensee and a copy of this report printed for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC809 (FAS) - (06/04)
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