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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608297
Report Date: 12/23/2024
Date Signed: 12/23/2024 11:21:15 AM

Document Has Been Signed on 12/23/2024 11:21 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BELLA VISTAFACILITY NUMBER:
197608297
ADMINISTRATOR/
DIRECTOR:		BAKER, IANFACILITY TYPE:
740
ADDRESS:1760 N FAIR OAKS AVETELEPHONE:
(626) 794-4103
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 72CENSUS: 36DATE:
12/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:Ian Baker - AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies to investigate the incident anonymously reported to Licensing on 12/16/2024 of a resident in the facility who is a hoarder. As a result of the hoarding, the facility currently has an infestation of roaches. LPA met with the Administrator, Ian Baker and explained the purpose of the visit.

During the visit, LPA obtained copies of the staff and resident rosters, house rules and requested copies of the pest control service reports/invoices. LPA interviewed the Administrator and attempted to interview Resident #1 (R1) who has limited verbal and hearing skills and was unsuccessful. Per information obtained from the interview, R1 did not want his room to be cleaned by staff and becomes aggressive to staff when they attempt to clean his room. Administrator indicated that he has expressed their concern about R1's hoarding to the Regional Center during their regular meetings. On 12/12/2024, Administrator stated that he reported the hoarding and roach incident to the Regional Center again. Administrator scheduled a pest control service and the exterminator came to spray R1's room on 12/14/2024. At 9:40am, LPA conducted a tour of the facility's common areas and R1's room and observed dead roaches in the bedroom and bathroom (photos available). Based on LPA’s observations, interviews, and record reviews, the alleged incident occurred at this time.



Deficiency is cited on LIC 809D. Exit interview, a copy of this report and Appeals Rights were provided to Ian Baker, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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Document Has Been Signed on 12/23/2024 11:21 AM - It Cannot Be Edited


Created By: Bennette Pena On 12/23/2024 at 10:40 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA VISTA
FACILITY NUMBER: 197608297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2024
Section Cited
CCR
87303(a)

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87303..Maintenance and Operation..(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include.. maintenance services .. for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Administrator will continue to have the facility specifically R1's room to be serviced by a pest control on a regular basis and submit copies of the exterminator's service report/invoices to LPA/CCL by POC due date.
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Based on LPA’s observations during the physical plant tour and interviews, LPA observed dead roaches in R1's bedroom and bathroom which poses a potential health, safety, and/or personal rights risk to the residents in care.
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
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