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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610053
Report Date: 11/17/2022
Date Signed: 11/17/2022 04:28:09 PM

Document Has Been Signed on 11/17/2022 04:28 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELLA NOVA VILLA IIFACILITY NUMBER:
567610053
ADMINISTRATOR:AYALA, MARIA S.FACILITY TYPE:
740
ADDRESS:1720 CORONADO PLACETELEPHONE:
(805) 242-6682
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 6DATE:
11/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Maria AyalaTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management deficiency visit to the above facility. LPA met with Administrator Maria Ayala at 12:35 p.m.

During a facility tour of the kitchen, starting at 12:22 p.m. LPA Ascencio observed 2 kitchen knifes in an unlocked cabinet accessible to resident in care. Staff stated they had just finished cooking and put the knifes in the drawer to lock up later.

1 citation was issued during today's visit. The following deficiencies were observed (See LIC 809--D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and a copy of the report and appeal rights provided to Admin via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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 2
Document Has Been Signed on 11/17/2022 04:28 PM - It Cannot Be Edited


Created By: Angel Ascencio On 11/17/2022 at 01:58 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA NOVA VILLA II
FACILITY NUMBER: 567610053

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
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Staff placed knife in a locked kitchen drawer
during facility visit. Administrator will contract
an outside vendor to provide training. Admin
will provide documentation of staff inservice
regarding regulation 87705(f)(1) to CCL by
11/23/2022.
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Based on LPA's observation, the licensee did not comply with the section cited above as kitchen knife was observed in an unlocked kitchen drawer which poses an immediate health, safety and 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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