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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804101
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:48:27 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/01/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240801142746
FACILITY NAME:BELLA VISTA VILLAGE II, LLCFACILITY NUMBER:
496804101
ADMINISTRATOR:ROBLES, JESSICAFACILITY TYPE:
740
ADDRESS:18941 SONOMA HWYTELEPHONE:
(707) 712-2790
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:12CENSUS: 10DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Jessica Robles, AdministratorTIME COMPLETED:
12:04 PM
ALLEGATION(S):
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Facility staff did not ensure that medication disposal procedures are being followed.
Untrained staff are handling medications.
Facility staff is drinking alcohol on the job.
Lack of staff supervision resulted in resident injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on the above allegations.

Complaint alleges facility staff did not ensure that medication disposal procedures are being followed. Complainant states that facility Admin gave them medications belonging to deceased residents. During investigation, LPA received photographic evidence. Evidence provided does not necessarily establish the identity of the recipient of medications, type of medications photographed, or on what date medications were photographed. During investigation, LPA interviewed Admin. Admin stated medication destruction policy that is compliant with regulation. During investigation, LPA reviewed medical destruction record for four [4] residents that are now deceased (R1, R2, R3, and R4).


Continued on 9099C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20240801142746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELLA VISTA VILLAGE II, LLC
FACILITY NUMBER: 496804101
VISIT DATE: 11/07/2024
NARRATIVE
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Continued from 9099...

Each respective medical destruction record was present and compliant with regulation. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Complaint alleges untrained staff are handling medications. Complainant claims unauthorized handling of medications by caregivers at facility. During investigation, LPA reviewed evidence provided. Evidence provided does not necessarily show unauthorized handling of medication by caregivers. During investigation, LPA reviewed medication training records for five [5] out of five [5] staff. All five [5] staff members have received medication training, and completed the required test as outlined in HSC 1569.69(a)(5). So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Complaint alleges facility staff is drinking alcohol on the job. Complainant states that staff drink alcohol while working. During investigation, LPA interviewed for four [4] out of five [5] staff. Four [4] out of five [5] staff report they have never seen staff drinking alcohol while working. Four [4] out of five [5] staff reported that they have never seen staff stumbling or speaking with slurred speech. During investigation, LPA unable to obtain additional information to corroborate allegation. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Complaint alleges lack of staff supervision resulted in resident injury – Complainant states resident fell and broke their hip then passed away weeks afterward. Complainant unable identify resident. During investigation, LPA unable to obtain additional information to corroborate allegation.

Continued on 9099C(2)...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240801142746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELLA VISTA VILLAGE II, LLC
FACILITY NUMBER: 496804101
VISIT DATE: 11/07/2024
NARRATIVE
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Continued form 9099C...

So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. However, on 8/6/24 LPA observed zero staff present in Main Building and later only one staff present. However staff left to get a snack for a resident and at that time only LPA was present in Main Building, zero staff were present. This deficiency is being cited on a case management deficiencies, see 809 and 809D).
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/01/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240801142746

FACILITY NAME:BELLA VISTA VILLAGE II, LLCFACILITY NUMBER:
496804101
ADMINISTRATOR:ROBLES, JESSICAFACILITY TYPE:
740
ADDRESS:18941 SONOMA HWYTELEPHONE:
(707) 712-2790
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:12CENSUS: DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Jessica Robles, AdministratorTIME COMPLETED:
12:04 PM
ALLEGATION(S):
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Facility staff did not ensure residents dietary needs are being met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on the above allegation.

Complaint alleges facility staff did not ensure residents dietary needs are being met. Complainant states dietary restrictions and special diet needs of residents are not being observed. During investigation, LPA reviewed ten [10] out of ten [10] resident’s physician reports and appraisals. Eight [8] out of ten [10] residents have either a dietary restriction or special dietary need as indicated on their respective physician’s report and/or appraisal. During investigation, LPA interviewed four [4] out of five [5] staff. Four [4] out of five [5] staff did not correctly identify all respective residents’ dietary restrictions and/or special dietary needs. Based on LPA’s interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240801142746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BELLA VISTA VILLAGE II, LLC
FACILITY NUMBER: 496804101
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2024
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
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Facility to submit LIC9098 self-certifying Admin has reviewed all residents' dietary restrictions and/or special dietary needs with all staff. Admin will also put up chart of dietary needs/restrictions in kitchen for all staff by plan of correction due date.
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This requirement was not met by licensee as evidenced by: Based on LPA interviews and record review, four [4] out of five [5] staff did not correctly identify all respective residents’ dietary restrictions and/or special dietary needs, which poses a potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5