565802001-9-16-2024-29-AS-ECOZ-D974FA-20240916190337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802001
Report Date: 09/16/2024
Date Signed: 09/16/2024 07:04:29 PM

Document Has Been Signed on 09/16/2024 07:04 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
WOODLAND HILLS N.ASC, 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:	09/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Maria Ayala		TIME COMPLETED:	07:05 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) Esther Cortez conducted an unannounced required annual visit to the above facility. LPA met with the Administrator Maria Ayala and explained the reason for the visit. Medication Audit: At 3:20 p.m. a medication audit for three (3) residents was initiated. The following was observed: The medications were stored in a locked kitchen cabinet which is locked and inaccessible to the residents in care; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. During Resident #1 (R#1's) audit, the LPA observed the following over the counter medications without a prescription, D-Mannose with Cranberry & Hibiscus 1,300 mg. Upon observation the Administrator stated that R1's family member had brought that medication. R1's family member was contacted and confirmed they had brought that medication in error in place of the prescribed Cranberry extract 500mg, and was able to bring the correct medication during the visit. At 03:51 p,m. the LPA toured the physical plant areas inside and outside with the administrator to ensure there are no health and safety hazards. LPA tested the smoke alarms and carbon monoxide detector which functioned properly. The fire extinguisher was recently purchased in August of 2024. KITCHEN: Kitchen knives are stored in a locked cabinet in the kitchen along with the medications. The supply of dishes, utensils, pots, pans and drink ware is adequate.. The supply of perishable and nonperishable food is adequate. There are no toxins in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Kitchen, laundry and house cleaning supplies are stored in the locked garage. No flies or other vermin were observed. The garage was observed locked and contained the emergency food supply, and a laundry area that contained laundry supplies. Report will continue on LIC809-C. (2ND PAGE).

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

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

FACILITY NAME: BELLA NOVA VILLA	FACILITY NUMBER: 565802001
	VISIT DATE: 09/16/2024

NARRATIVE

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Bedrooms: There are two (2) shared rooms and two (2) single rooms. All resident rooms had appropriate furnishings, clean linens, and adequate lighting.

Restrooms: There are three (3) total bathrooms at the home. One (1) is designated as a staff bathroom, one (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. Hot water temperature was measured at 113.5*F in both resident bathrooms.

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. LPA observed the required postings in the common hallway. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted.

Record Review: At 4:28 p.m. a review of facility files was initiated. The LPA reviewed five (5) out of six (6) resident files. The following was observed: One resident (R2) did not have their required updated Physician medical assessment (LIC602) due to their Dementia diagnosis. Upon observation the administrator stated that they had taken R2 to get their physical already however, the Physicians office did not want to release the form until the TB results were out. The administrator called R2's physician office and they confirmed that the physical was done and awaiting TB results and stated they would be sending it soon. The LPA advised the Administrator to review R3’s file, as their LIC602 indicated that R3 was bedridden, however the LPA observed R3 able to move and walk. The LPA reviewed four (4) out of seven (7) staff files. Al files were complete and current.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit inter view conducted and copy of the report and appeal rights provided to Administrator Maria Ayala.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 09/16/2024 07:04 PM - 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA NOVA VILLA	FACILITY NUMBER: 565802001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(5)(A)

Incidental Medical and Dental Care Services

(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician. 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 in one out of one over the counter medications for R1 without a prescription which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	Upon observation Administrator had R1's family member bring the correct medication and discarded of the wrong OTC medication. Administrator agreed they will submit a letter of understanding regulation 87465 by 09/17/2024

Section Cited


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

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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