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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804101
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:46:28 AM

Document Has Been Signed on 11/07/2024 11:46 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BELLA VISTA VILLAGE II, LLCFACILITY NUMBER:
496804101
ADMINISTRATOR/
DIRECTOR:		ROBLES, JESSICAFACILITY TYPE:
740
ADDRESS:18941 SONOMA HWYTELEPHONE:
(707) 712-2790
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 12CENSUS: DATE:
11/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Jessica Robles, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst Christi Coppo arrived unannounced to conduct a Case Management - Deficiencies and met with Administrator, Jessica Robles.

On 8/6/24 LPA was present at facility in order to conduct an annual inspection and open a complaint investigation. While LPA was present at the facility, LPA observed zero staff present in the Main House and later observed one staff present in the Main House. However, the one staff that was present left to get a snack for a resident leaving zero staff present.

Today, on 11/7/24 LPA arrived to the facility to deliver findings on a complaint investigation. Upon arrival, LPA went to the Main House and observed zero staff present.

During investigation, LPA reviewed ten [10] out of ten [10] residents’ physician reports and appraisals. The reviewed physician’s reports and/or appraisals indicate that

· 9 residents have either wandering behavior or sundowning behavior

· 3 are identified as being a fall risk

· 10 require assistance (extensive or full) with bathing

· 10 require assistance (extensive or full) with dressing and/or grooming

· 10 require assistance (extensive or full) with toileting and/or incontinence care

· 9 require some type of ambulatory assistance including but not limited to transfer assistance

· 3 are unable to feed themselves

Continued on 809C...

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.

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
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
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Continued from 809...

LPA review of staff schedule indicates that no more than 2 staff are present at the Main House at any given time. The facility is set up as a series of 3 independent cottages (detached and across from the main house) with a main house containing 4 bedrooms. The facility kitchen and laundry are across the driveway from the main house at the end of the aisle of the cottages. This means that staff must leave the main house entirely to get food from the kitchen, do the laundry, and attend to the residents in the cottages. Facility also has locked entrance that requires all visitors be buzzed in, the location of the buzzer was outside of both the cottages and the main house both times LPA visited the facility. This means staff must leave the main house or cottage to permit visitors to enter the facility. Additionally, a staff the takes the visitors' temperature and has them sign in, which also takes time. Based on the care needs indicated by the residents’ respective appraisals and physician’s reports, and the current staff roster and staff schedule, it appears that the facility does not have enough staff to meet the various possible care needs of residents at any one given time (deficiency cited, see 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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2024 11:46 AM - It Cannot Be Edited


Created By: Christi Coppo On 11/07/2024 at 10:31 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
, 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
11/21/2024
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by licensee as evidenced by:Based on LPA observation and record review,
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Facility to submit LIC500 showing staff sufficient in numbers to meet the various possible care needs of residents at any one, by plan of correction due date. LPA and Admin discussed adding a part-time employee for at least 20 hours per week. Admin to submit LIC500 and all documents gathered to hire part time employee by plan of correction due date. Should Admin need more time for fingerprint clearance or any otjer unforseen issue, Admin to contact CCL for extension.
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staff not present or not present in sufficient in numbers in Main House, based on the care needs indicated by the residents’ respective appraisals, physician’s reports, and the current staff roster and schedule, it appears that the facility does not have enough staff to meet the various possible care needs of residents at any one given time, which poses an 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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