567610053-9-25-2023-29-AS-TCAA-CVZKTA-20230925081049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610053
Report Date: 09/22/2023
Date Signed: 09/25/2023 08:11:26 AM

Document Has Been Signed on 09/25/2023 08:11 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BELLA NOVA VILLA II		FACILITY NUMBER:	567610053
ADMINISTRATOR:	AYALA, MARIA S.		FACILITY TYPE:	740
ADDRESS:	1720 CORONADO PLACE		TELEPHONE:	(805) 242-6682
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	6	CENSUS: 6	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Maria Ayala		TIME COMPLETED:	04:45 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) Teresa Camara conducted an unannounced required annual visit to the above facility. LPA met with the Administrator Maria Ayala and explained the reason for the visit. LPA toured the physical plant areas inside and outside 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 2023. Hot water temperature was measured at 119.8F. BEDROOMS:* There are six 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, 1 is in the common hallway, 1 restroom is in a bedroom for resident use. The resident bathrooms have a shower with non-skid materials. The toilet and showers have grab bars. 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. Kitchen knives are stored in a locked closet in the hall along with the medications. Medications were reviewed and appeared to be given as prescribed. (continued on 809-C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 II	FACILITY NUMBER: 567610053
	VISIT DATE: 09/22/2023

NARRATIVE

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(continued from 809)

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 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.

INFECTION CONTROL: LPA spoke with the Admin regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. The administrator requests visitors wear at mask.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. The facility’s policies and procedures as it pertains to infection control are adequate.

LPA reviewed six resident files and six employee files which were complete.

Exit interview conducted and copy of the report provided to administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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