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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201202
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:11:09 PM

Document Has Been Signed on 11/04/2022 04:11 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BELLA VISTAFACILITY NUMBER:
019201202
ADMINISTRATOR:BAUTISTA, HAIDIEFACILITY TYPE:
740
ADDRESS:1641-1659 D STREETTELEPHONE:
(510) 397-0751
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 42CENSUS: 15DATE:
11/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Haidie Bautista/Applicant-administratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Delmundo conducted pre-licensing inspection. License application is for fourty two (42) total capacity, of which twenty six (26) may be non-ambulatory. Fire clearance was granted on August 8, 2022. Application is for change in facility type to Residential Care Facility for Elderly (RCFE) and facility is currently in operation. LPA called and spoke with Haidie Bautista who authorized Sally Espina, staff, to be with LPA during inspection. Applicant arrived after about 20 minutes.

LPA started the inspection with Sally Espina and continued with Haidie Bautisa. The facility comprises of two buildings. The main building will house the non-ambulatory. There is no body of water. LPA inspected the 2 buildings including but not limited to living rooms, dining areas, kitchens, bedrooms, bathrooms, shower rooms, front, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed sufficient good for seven days of non-perishables and 2 days of perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinets were knives, and medication carts and cabinets were medications are centrally stored were observed locked. Toliets and bathrooms/showers were observed equipped with grab bars and non-skid mats. Complaint poster, Ombudsman and Personal Rights posters, Rights to Resident Council and Rights to Family Council were observed posted in the prominent place.

A central screening station for staff and visitors were observed set-up by entrance door in the 2 buildings. Facility has central storage for PPEs and observed adequate for 30 days. Facility's Infection Control Plan with Monkeypox Addendum were submitted by applicant and received by LPA on 10/18/2022.

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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BELLA VISTA
FACILITY NUMBER: 019201202
VISIT DATE: 11/04/2022
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Fire extinguishers checked and observed fully charge with tags showed serviced February 2, 2022. Carbon monoxide and smoke detectors operational. First aid kit inspected. Facility has flash lights for emergency lighting. Hot water temperature in one of the common bathrooms was tested. Facility has land line phone which is in operating condition.

LPA observed the following:
1. No auditory alarms on all entrance and exit doors.
2. No signal system on both buildings and no call buttons for residents' use.
3. Hot water temperature was measured at 122 degrees Fahrenheit.
4. Beds have no mattress pads. Staff put mattress pads on the beds while LPA was at the facility.
5. No "Wear Masks" posters in common areas, dining room and activity room. Applicant posted posters while LPA was at the facility.
6. Facility's Theft and Loss Policy not posted. Applicant posted the document while LPA was at the facility.

Copy of staff's current N95 Fit Testing certificates and $3M liability insurance certificate submitted to LPA on this same day.

LPA reminded applicant of updating residents and staff files to reflect facility name and number once license is granted.

LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application and license to be granted by CAB analyst.

Exit interview conducted and copy of this report provided to Haidie Bautista.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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