565802001-9-21-2022-29-AS-AASO-CJGPX8-20220921114156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802001
Report Date: 09/20/2022
Date Signed: 09/21/2022 11:56:37 AM

Document Has Been Signed on 09/21/2022 11:56 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BELLA NOVA VILLA		FACILITY NUMBER:	565802001
ADMINISTRATOR:	AYALA, MARIA		FACILITY TYPE:	740
ADDRESS:	1111 IVYWOOD DRIVE		TELEPHONE:	(805) 983-6720
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	6	CENSUS: 6	DATE:	09/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:36 PM
MET WITH:	Maria Ayala		TIME COMPLETED:	04:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced required annual visit to the above facility. LPA Ascencio met with the Administrator Maria Ayala and explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures. At 2:40 p.m., the LPA, along with staff member toured the physical plant areas inside and outside to ensure there are no health and safety hazards. BEDROOMS: All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are 4 (four) total bedrooms for resident use – two (2) rooms are shared and 2 are private. RESTROOMS: There are three (3) total bathrooms at the home. One (1) is designated as a staff bathroom, 1 is in the common hallway, 1 restroom is in a shared bedroom for resident use. The resident bathrooms have a shower with non-skid materials. The toilet and showers have grab bars. Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA NOVA VILLA	FACILITY NUMBER: 565802001
	VISIT DATE: 09/20/2022

NARRATIVE

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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and
good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system was tested in each individual room and common area and operated normally at the time of visit. Medications were observed to be locked in a cabinet in the kitchen and contained at least 30 days of worth of medication. The garage was observed locked and contained the emergency food supply, and a laundry area that contained laundry supplies. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted.

KITCHEN: Kitchen knives are stored in a locked cabinet in the kitchen. The supply of dishes,
utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees
Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in the garage. No flies or other vermin were observed

INFECTION CONTROL: During today’s visit, the LPA spoke with the Admin regarding the
facility’s infection control practices at 3:40 p.m. There is 1 entry into the facility. Upon entry, the
facility has a central entry point for symptom screening. The LPA noted that the facility is allowing
visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal
Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The
facility’s cleaning protocol is sufficient.

Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA NOVA VILLA	FACILITY NUMBER: 565802001
	VISIT DATE: 09/20/2022

NARRATIVE

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If needed, the facility has the capacity to designate a single isolation room if the facility has a
confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

During today's facility tour while checking facility water temperature starting at 2:40 p.m., LPA observed the kitchen water temperature reading of 134.4.F, shared bathroom water temperature at 134.7.F and hallway bathroom hot water temperature at 130.2 F. Starting at 02:50 p.m., LPA observed 2 window screens and 1 slide door screen cover ripped or torn off. 1 window screen cover was removed in Resident #1 (R1) room.

2 citations were issued during today’s visit. The following deficiencies were observed (See
LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California
Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, copy of report and appeal right provided to admin via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2022 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA NOVA VILLA	FACILITY NUMBER: 565802001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as 2 window screen covers were torn or removed and backyard sliding door screen cover was torn which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2022
	Plan of Correction
1 2 3 4	Licensee stated they will repair all window screen covers and the backyard sliding screen door. Licensee will take a picture and submit proof to LPA Ascencio via email by 09/30/2022.

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the kitchen water temperature was 134.4 F, shared bathroom water temperature read 134.7 F and hallway bathroom water temperature read at 130.2 F, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2022
	Plan of Correction
1 2 3 4	Licensee stated they will lower the hot water temperature. Licensee will take hot water temperature readings 3 times a day for 3 days. Licensee will submit temperature readings to LPA via email by 09/30/2022.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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