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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610053
Report Date: 09/06/2024
Date Signed: 09/06/2024 07:27:20 PM

Document Has Been Signed on 09/06/2024 07:27 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELLA NOVA VILLA IIFACILITY NUMBER:
567610053
ADMINISTRATOR/
DIRECTOR:		AYALA, MARIA S.FACILITY TYPE:
740
ADDRESS:1720 CORONADO PLACETELEPHONE:
(805) 242-6682
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 6DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Maria AyalaTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
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At 10:15 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and a resident's family member and informed them of the reason for the visit. Administrator Maria Ayala arrived approximately at 11:00 a.m .

When the LPA arrived they observed staff #1 and a resident's family member (F1), who is not finger-printed cleared at the dining table going through resident medication records. F1 proceeded to put all files away in the hallway closet where the files and resident medications are stored.

At 10:20 a.m. the LPA conducted a tour of the physical plant with staff to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms, two (2) resident restrooms, and one (1) staff restroom. The LPA observed fire extinguishers which were fully charged and last purchased in July 2024. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Snacks and beverages are always available for the residents. Knives are stored in a locked closet, and cleaning supplies are stored in locked cabinet, and in the locked garage.
Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding. Starting at 10:30 a.m.,the LPA observed the auditory alarms in the exist doors of rooms #1, #3 and #6 to not be operable. At 10:32 a.m. the LPA observed the exit door in room #3 blocked with an arm chair. At 10:39 a.m. the LPA observed the exit door in room #6 blocked with a walker, and chairs. Upon observation, staff removed items from the exit doors. Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLA NOVA VILLA II
FACILITY NUMBER: 567610053
VISIT DATE: 09/06/2024
NARRATIVE
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Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 11:40 a.m. water temperature in resident’s restroom in room #6 was measured at 135.3 degrees Fahrenheit. At 11:43 a.m. water temperature in the common restroom was measured at 135.5 degrees Fahrenheit. At 11:48 a.m. the water temperature in the kitchen measured at 136.6 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the first living room, which is covered with a screen. At 10:33 a.m. the LPA observed the light in the hallway leading to the common restroom inoperable.



The garage: The LPA observed the garage where additional supplies and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in the garage. The garage is locked.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. The LPA observed the outdoor furniture with spider webs and dust.

Record Review: At 12:38 p.m. a review of facility files was initiated. The LPA reviewed four (4) out of seven (7) staff files. The following was observed: Administrator's file was missing, and all staff records reviewed did not have the required annual training, and three staff did not have a current 1st aid/CPR certificate. In addition Staff #2 (S2) had a Health screening (LIC503) that belong to another staff with their name white-out and S2's name written over. Upon observation the Administrator stated that about a month ago certain staff and residents files had been stolen or altered by previous employees who no longer work at the facility. However the incident was never reported to CCL.

The LPA reviewed five (5) out of six (6) resident files. The following was observed: One out five residents did not have TB results on file, otherwise all files were complete.

Report will continue on LIC809-C (3rd page).
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLA NOVA VILLA II
FACILITY NUMBER: 567610053
VISIT DATE: 09/06/2024
NARRATIVE
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Medication Audit: At 3:20 p.m. a medication audit for two (2) residents was initiated. The following was observed: The medications were stored in a locked closet which is locked and inaccessible to the clients. During Resident #1 (R#1's) audit, the LPA observed the quantity for all medications not documented on the Centrally Stored Medication and Destruction Record (CSMDR) and Bupropion medication not recorded at all. In addition, according to the start date on the CSMDR, and the quantity on the medications prescription label R1's Levothyrozine Sodium 25mcg should have seventeen (17) tablets on the bubble pack, however the LPA observed twenty-three (23) tablets on the bubble pack. During R#2’s audit, the LPA observed an excessive amount of extra medications stored in the garage, which the administrator stated they did not know what to do with as they were extra medications.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit inter view conducted and copy of the report and appeal rights provided to Administrator Karina Rosales Antig.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/06/2024 07:27 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/06/2024 at 06:22 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: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in three sinks where the water tempearature measured over 130 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/07/2024
Plan of Correction
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The administrator agrees to adjust the water temperature and submit proof and log for five (5) days of the water temperature within the required temperatures of 105F-120F.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in two rooms that had furniture and a other items blocking the exits which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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2
3
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POC has been met. Staff removed all items blocking the room exits leading outside.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 09/06/2024 07:27 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/06/2024 at 06:22 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: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as a family member was observed to be going through residents medication files, helping a staff with their duties, and had access to the residents medication files and medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2024
Plan of Correction
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Administrator agrees to write a letter of understanding of regulation 87355 in its entirety and agree to not have any individual work at the facility without being finger printed cleared and associated to the facility.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(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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2
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Based on medication audit, the licensee did not comply with the section cited above as the LPA observed more meication tablets than the resident should have based on the quantityh and start day which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2024
Plan of Correction
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Administrator agrees to submit a plan on how they will ensure the health and safety of the residents in regards to their medication intake, which should include staff medication training and submit to CCL by 9/7/24, and submit proof of staff training by 9/13/24.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 09/06/2024 07:27 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/06/2024 at 06:22 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: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the hallway ligh leading to a non private restroom was inoperable which poses a potential health and safety risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Administrator agrees to fix the lighting in the hallway and submit proof to CCL by 09/16/24.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in three staff that did not have 1staid/CPR training on file which poses a potential health and safety risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Administrator agrees to have all three staff obtain 1st aid/CPR training and submit proof by 09/16/24.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 09/06/2024 07:27 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/06/2024 at 06:22 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: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as the administrator's file was missing and additional stall records which poses a potential health and safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Upon observation the Administrator stated that files had been stolen. Administrator agrees to conduct a staff file audit and ensure all files are current and complete. In addition the administrator will submit a incident report, and file a police report to report the theft. Everything should be submitted to CCL by 9/20/24.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as one staff had a health screening that belong to a different staff with their name whited out and new staff name written on top which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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2
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Administrator agrees to have staff obtain a new health screeing from their physician and submit to CCL by 9/16/24.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 09/06/2024 07:27 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/06/2024 at 06:22 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: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in four staff that did not have annual required training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
1
2
3
4
Administrator agrees to have all staff obtained their required annual staff training and submit proof to CCL by 9/23/24.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one resident who did not have a TB test results in their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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2
3
4
Adminsitrator agrees to have resident obtained TB test result from their physician and submit proof to CCL by 9/6/24.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


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