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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201202
Report Date: 10/24/2024
Date Signed: 10/24/2024 07:10:28 PM

Document Has Been Signed on 10/24/2024 07:10 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/
DIRECTOR:		BAUTISTA, HAIDIEFACILITY TYPE:
740
ADDRESS:1641-1659 D STREETTELEPHONE:
(510) 397-0751
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 42CENSUS: 34DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Haidie Bautista/Administrator
and Sally Espina/House Manager		TIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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On this day, October 24, 2024, at 1:15 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with House Manager Sally Espina and Haidie Bautista, administrator, and informed the reason for visit.

LPA started the inspection with house manager and continued with administrator. LPA inspected the 2 buildings (Bldg A and Bldg B) including but not limited to common areas, kitchens, dining areas, receiving room, library, bathrooms, shower rooms, toilets, front, side and backyard. LPA selected for inspection 4 residents rooms in Bldg B and 7 in Buiding A. Fire extinguishers were observed fully charge with tags showed serviced May 21, 2024. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables.

Central storage for medications and medication carts were locked. All residents rooms, dining and common areas were equipped with electric fans. Hallways, common areas, yards and porch were observed free of hazards.

Facility has smoke and carbon monoxide detectors that were observed functional. Hot water temperature in one of the bathrooms in Bldg A was tested and measured at 118.4 degrees Fahrenheit. Facility conducts disaster drills every quarter and records showed last conducted October 14, 2024.

LPA reviewed 5 residents and 5 staff files, and interviewed 4 residents. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.

.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BELLA VISTA
FACILITY NUMBER: 019201202
VISIT DATE: 10/24/2024
NARRATIVE
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LPA observed the following:
-at 1:30 p.m., greasy cooking range and grease deposits in the corner of flooring in the kitchen in Bldg A.
-at 1:38 p.m., vinyl flooring tiles in Bldg B coming off.
-at 1:40 p.m., mildew in the shower and broken faucet in Bldg B.
-at 1:56 p.m., chipped electrical outlet plate in one of the resident's rooms in Bldg A.
-at 5:15 p.m., resident's (R1) medications filled on 10/02/24 & 10/21/24 has no LIC622. R1 has doctor's order for Ferrous Sulfate but facility does not have this medication.
-at 5:50 p.m., staff crossed-out one of resident's (R2) medications on the label.

LPA received updated copies of the following documents:
1. LIC308 Designation of Facility Responsibility
2. LIC610E Emergency Disaster Plan
3. LIC9282 Infection Control Plan
4. $3M liability insurance certificate

Administrator to submit a copy of updated LIC500 Personnel Report by 11/07/24.

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 and plan and proof of corrections were discussed with the 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: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/24/2024 07:10 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/24/2024 at 06:15 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: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in greasy cooking range and grease deposits in corner of flooring in the kitchen in Bldg A which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Corrected.
Staff cleaned the range and kitchen floor.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in following which pose a potential health, safety and/or personal rights risks to persons in care: vinyl flooring tiles in Bldg B coming off; mildew in the shower and broken faucet in Bldg B; chipped electrical outlet plate in one of the resident's rooms in Bldg A.
POC Due Date: 11/07/2024
Plan of Correction
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Administrator have the shower cleaned, and faucet and electrical outlet replaced.

Administrator to have the tiles replaced and submit pictures by 11/07/24:
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: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/24/2024 07:10 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/24/2024 at 06:32 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: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section when staff crossed-out one of resident's (R2) medications on the label which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Administrator to in-service the staff and submit proof by 11/07/24.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having LIC622 for resident's (R1) medications filled on 10/02/24 & 10/21/24] which poses a potential health and/or personal rights risk to person in care.
POC Due Date: 11/07/2024
Plan of Correction
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Corrected.
Administrator completed the LIC622.
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: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2024 07:10 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/24/2024 at 06:39 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: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R1 having doctor's order for Ferrous Sulfate but facility does not have this medication which poses an immediate health risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Administrator to check with the doctor and obtain the medication if still needed; otherwise, obtain discontinued order. Proof to be submitted by 10/25/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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