Community Care Licensing

SUPERVISOR'S NAME: Victoria Bertozzi TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Christi Coppo TELEPHONE: (707) 588-5054 LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

FACILITY NAME: BELLA VISTA VILLAGE II, LLC	FACILITY NUMBER: 496804101
	VISIT DATE: 08/06/2024

FACILITY NAME: BELLA VISTA VILLAGE II, LLC	FACILITY NUMBER: 496804101
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type A

Section Cited

CCR

87355(e)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin record review, the licensee did not comply with the section cited above in that per Guardian, S6 fingerprint application was received 3/29/2023 and closed for incomplete application on 6/27/2023, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	Facility to submit LIC9098 self-certifying that S6 will not be present at or working in the facility until such time have they obtained fingerprint clearance and are associated to the facility. LIC9098 to be submitted by plan of correction due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Victoria Bertozzi TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Christi Coppo TELEPHONE: (707) 588-5054 LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Document Has Been Signed on 08/06/2024 04:17 PM - It Cannot Be Edited

FACILITY NAME: BELLA VISTA VILLAGE II, LLC	FACILITY NUMBER: 496804101
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation, the licensee did not comply with the section cited above in that bedroom #4 in Memory Care main house had broken wall outlet cracked and missing the right side portion of face plate and internal box visible. Half bath in Memory Care main house did not have working fan or lights, switches did not work, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	Facility to submit pictures/video of working lights anf an in half bath of Memory Care main unit and picture of repaired/replaced wall outlet faceplate by plan of correction due date.

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that five [5] out of [6] staff, S1, S2, S3, S5, and S6 did not have current annual training completed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	Facility to submit proof of completed training for S1, S2, S3, S5, and S6 by plan of correction due date on completed training log. If training is completed by an approved vendor, training materials do not need to be submitted to CCL prior to conducted training. If facility does not choose an approved vendor to complete staff training, materials must first be submitted to CCL for approval before completing training.

SUPERVISOR'S NAME: Victoria Bertozzi TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Christi Coppo TELEPHONE: (707) 588-5054 LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Document Has Been Signed on 08/06/2024 04:17 PM - It Cannot Be Edited

FACILITY NAME: BELLA VISTA VILLAGE II, LLC	FACILITY NUMBER: 496804101
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type B

Section Cited

CCR

87555(b)(8)

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation, the licensee did not comply with the section cited above in that Food items were found to be uncovered in the refrigerator such as watermelon, grains and cereals in canisters without dates of filling/opening, and canned and boxed goods found with expired best if used by dates: various brands of peanut butter with best if used by dates of 8/28/2023,12/7/2023, 5/15/2024, and 1/16/2024; canned mini raviolis with best if used by date of 6/5/2023; box of Rice a Roni with best is used by date of 2/14/2024; can of Manwich with best if used by date of 11/22/2023, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	Facility discarded all identified items while LPA present. Deficiency cleared.

Type B

Section Cited

CCR

87463(c)

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation, the licensee did not comply with the section cited above in that three [3] out five [5] residents R1, R2, and R3 did not have a current appraisal, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	Facility to submit copies or pictures of current appraisal for R1, R2, and R3 by plan of correction due date.

SUPERVISOR'S NAME: Victoria Bertozzi TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Christi Coppo TELEPHONE: (707) 588-5054 LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Document Has Been Signed on 08/06/2024 04:17 PM - It Cannot Be Edited

FACILITY NAME: BELLA VISTA VILLAGE II, LLC	FACILITY NUMBER: 496804101
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type B

Section Cited

CCR

87625(b)(3)

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation, the licensee did not comply with the section cited above in that PA and Admin observed bedroom #1 in Memory Care main house found to have strong urine smell, per Admin the urine smell is from the mattress. Shared room in cottage #2 had a bed that smelled strongly of urine, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	Facility to submit receipts for purchase of beds or receipts for professional cleaning of beds by plan of correction due date for bed in bedroom #1 in Memory Care main house and bed in cottage #2 by plan of correction due date.

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that R1 has a diagnosis of dementia but their most recent physician's report is dated 5/10/2023 and their appraisal is also dated 5/10/2023, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	Facility to submit to CCL copy of R1's current physician's report by plan of correction due date.

SUPERVISOR'S NAME: Victoria Bertozzi TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Christi Coppo TELEPHONE: (707) 588-5054 LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024