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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804101
Report Date: 10/06/2022
Date Signed: 10/06/2022 10:53:18 AM


Document Has Been Signed on 10/06/2022 10:53 AM - 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 VILLAGE II, LLCFACILITY NUMBER:
496804101
ADMINISTRATOR:ROBLES, JESSICAFACILITY TYPE:
740
ADDRESS:18941 SONOMA HWYTELEPHONE:
(707) 712-2790
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:12CENSUS: 8DATE:
10/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant, Jessica RoblesTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 10/6/2022 to conduct a pre licensing inspection. LPA met with applicant, Jessica Robles. This is a change of ownership with 8 residents in care.

LPA toured facility with applicant. The amount of fresh and nonperishable foods was within regulation. Toxins are secured and inaccessible. Medications are locked and centrally located. LPA recorded a water temperature of 112.5 degrees which is within regulation of of 105 and 120 degrees F at faucets accessible to residents. Bathrooms were equipped with necessary grab bars, non-slip floors/mats and had sufficient hygiene products. Fire extinguisher inspected was charged and dated 07/13/2022. Smoke detectors and carbon monoxide detectors were operational. LPA observed required postings (LTCO, CCL Complaint poster) in addition to COVID-19 postings. Facility is screening visitors at the front door which includes taking temperatures and requesting vaccination information.

Resident and staff files were available for review. LPA and applicant discussed the need for new admission agreements/addendums once new facility is licensed. LPA and applicant discussed CPR/First Aid training requirements for staff.

Comp III performed with applicant. LPA requested proof of liability insurance during visit. LPA will notify application unit to proceed with licensing.

Exit interview conducted with applicant.

LPA was unable to print this report. A copy was emailed to the applicant.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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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