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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201202
Report Date: 07/11/2023
Date Signed: 07/11/2023 06:28:52 PM

Document Has Been Signed on 07/11/2023 06:28 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: 38DATE:
07/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Haidie Bautista/AdministratorTIME COMPLETED:
06:30 PM
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While at the facility investigating a complaint (Control # 15-AS-20230705170957), and upon review of Facility Notes and interview, Licensing Program Analyst (LPA) Delmundo learned and observed the following:
1. Resident (R1) AWOLed on December 26, 2022, and according to Haidie Bautista, administrator, during interview on this day, July 11, 2023, she did not submit Unusual Incident Report to the Department.
2. Residents (R1 and R2) exhibited behaviors. R1 was at John George for 3 months and was discharged back to the facility on June 21.2023. These 2 residents do not have Pre-Admission Appraisal nor Re-appraisals.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies plan and proof of correction were discussed with administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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 3
Document Has Been Signed on 07/11/2023 06:28 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/11/2023 at 05:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELLA VISTA
FACILITY NUMBER: 019201202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2023
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports...
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence .........
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Administrator to read the Regulations and stated in the future she will submit an incident report as needed and in timely manner. Self-certification to be submitted by 7/25/23.
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-This is requirement is not met as evidenced by:

-Based on records review and interview, the licensee did not comply with the section above for not sending report for R1 when R1 AWOLed.
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Type B
07/25/2023
Section Cited
CCR87457(c)

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87457 Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission with the admission criteria....
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Administrator to complete the Pre-Admission Appraisals, and submit copies by 7/25/23.
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-This is requirement is not met as evidenced by:

-Based on records review and interview, the licensee did not comply with the section above for not completing Pre-Admission Appraisal for R1 and R2,
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/11/2023 06:28 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/11/2023 at 05:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELLA VISTA
FACILITY NUMBER: 019201202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2023
Section Cited
CCR
87463(b)

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87463 Reappraisals
(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.
-This requirement is not met as evidenced by:
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Administrator stated she will reach out to the resident's care team to set-up an appoitnment with residents' psychiatrist and pcp and will complete re-appraisals by 7/25/23.
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- Based on records review and interview, the licensee did not comply with the section above for not bringing the changes and/or observation of R1 and R2's behaviors to the primary care phycian (pcp) and psychiatrist.
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
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