Bella Vista

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit. LPA met with Ian Baker, the Administrator and explained the purpose of the visit. Facility is licensed to serve elderly residents age 60 and above, fire clearance approved for (72) non-ambulatory. Hospice approved for ten (10) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan. Staff are adhering to infection control requirements. Emergency and disaster plan was completed and up to date. Infection control practices and Personal Protective Equipment (PPEs) were maintained. Operational Requirements: The Infection Control Plan has been added to the Plan. Facility is approved for (10) hospice residents, 87705 compliant. A fire clearance is in place. Fire Drill was last conducted on 1/15/2026. A Valid Liability Insurance and Valid Surety bond are in place. Physical Plant/Environment Safety: The facility is a two-story building located in a residential community. The facility consists of: First floor: Lobby, Administrative offices, Conference room, Supply room, Power/Telephone room, Kitchen, Janitor room and Elevator. Second floor: (35) resident bedrooms, Medication room, Library, Activities room, five (5) shower rooms, staff room, Beauty shop, Doctor's office/Nurse station and Dining room. [Continue to LIC809-C] Physical Plant/Environment Safety [Cont.]: The interior and exterior physical plant was inspected. Kitchen was inspected, knives, sharps objects, cleaning supplies and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. Carbon monoxide detectors were tested and operable. Evacuation chairs are located by the stairways. LPA tested hot water temperature in four (4) shower rooms and water temperature readings measured between 105.6 degrees F to 112.4 degrees F which are within the required 105 - 120 degrees Fahrenheit. Staffing: Facility employs a sufficient number of staff including night staff that are trained and able to provide care and supervision to the residents in the event of an emergency. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility. Personnel Records/Staff Training: LPA reviewed five (5) staff files which included personnel record, health screenings, TB clearance, staff training, valid Food Handler’s Certificate, and First Aid/CPR/AED training. Administrator’s Certificate expires on 01/12/2027. Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Facility provides internet services to all residents and they have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed the activities calendar posted in the activity room and displayed on the tv screen by the elevator. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Cleaning supplies are stored in areas separate from food supplies. Sanitation practices and kitchen cleanliness was observed. Per Administrator, there are two (2) residents with modified diets but facility has dietician that makes frequent site visits. Incidental Medical and Dental: LPA reviewed five (5) resident medications were reviewed and had no issues. Medications are centrally stored and contain 30-day supply of medications. Medical and dental transportation is provided. LPA observed the First Aid kit that has all required items. Resident Records/Incident Reports: Resident files are maintained at the facility. LPA reviewed five (5) resident files which included Face Sheet, Identification and Emergency Information, Admission Agreements, Physician's Reports, TB clearance, Ambulatory Status, Individual Program Plan, Appraisal/Needs and Services Plan, and Personal Rights. RCFE complaint poster and Personal rights were observed posted. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills. Residents with Special Health Needs: Per Administrator, no hospice and/or bedridden residents and have no residents have prohibited health conditions.. There are no residents using oxygen. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit interview was held and a copy of this report was provided to the Administrator, Ian Baker.the state’s words, verbatim · CDSS document, May 26, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent Required- 1 year visit. LPA met with Greg Tillman, Administrative Assistant and explained the purpose of the visit. Shortly after, Ian Baker, Administrator arrived and assisted LPA with the inspection. There are currently thirty four (34) residents residing in the facility. Facility is licensed to serve elderly residents age 60 and above, fire clearance approved for (72) non-ambulatory. Hospice approved for ten (10) residents, 87705 compliant. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: Lobby, Administrative offices, Conference room, Supply room, Power/Telephone room, Kitchen, Janitor room and Elevator. Second floor: (36) resident bedrooms, Medication room, Library, Activities room, Staff room, Beauty shop, Doctor's office/Nurse station and Dining room. The interior and exterior physical plant was inspected. Kitchen was inspected, knives, sharps objects, cleaning supplies and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are cameras without audio in the hallways and common areas. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. LPAs tested hot water temperature in random resident rooms and water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Staffing: A total of twenty (20) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. *****CONTINUED ON LIC809-C***** Personnel Records/Staff Training: LPA reviewed (5) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and First Aid/CPR training, however (2) out of (5) staff have expired First aid/CPR training. Administrator's certificate expired on 01/12/2025, but renewal has been submitted. Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed the activities calendar posted in the activity room and displayed on the tv screen by the elevator. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Cleaning supplies are stored in areas separate from food supplies. Sanitation practices and kitchen cleanliness was observed. Incidental Medical and Dental: Resident medications were reviewed; centrally stored and containing 30-day supply of medications. Medical and dental transportation is provided. Resident Records/Incident Reports: Resident files are maintained at the facility. A total of (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Residents with Special Health Needs: No hospice and/or bedridden residents. There are no residents using oxygen. No residents have prohibited health conditions. Deficiency issued on LIC809-D. An exit interview was conducted, and a copy of this report was provided to Ian Baker, Administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, Jun 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Greg Tillman, Administrative Assistant and explained the purpose of the visit. LPA was informed that the Administrator, Ian Baker is out on vacation. There are currently thirty four (34) residents 60 years and older residing in the facility. Facility is licensed to serve elderly residents age 60 and above, fire clearance approved for (72) non-ambulatory. Hospice approved for ten (10) residents, 87705 compliant. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan. Staff are adhering to infection control requirements. Emergency and disaster plan was completed and up to date. Infection control practices and Personal Protective Equipment (PPEs) were maintained. Operational Requirements: The Infection Control Plan has been added to the Plan. Facility is approved for (10) hospice residents, 87705 compliant. A fire clearance is in place. Fire Drill was last conducted on 3/07/2025. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 01/01/2026. Surety bond is in place. Due to time constraints, LPA was unable to complete the following domains and will return at a later date to complete this required- 1 year inspection. Physical Plant/Environment Safety Staffing Personnel Records -Training Resident Rights - Information Planned Activities Food Service Incident Medical and Dental Resident Records/Incident Reports Disaster Preparedness Residents with Special Health Needs No deficiencies were observed during the visit. Exit interview held and a copy of the report was provided to Greg Tillman, Administrative Assistant.the state’s words, verbatim · CDSS document, Jun 16, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Health Checks visit regarding the repopulation of the residents back in the facility. Administrator stated that on 1/10/2025, residents at Bella Vista 1760 N Fair Oaks Ave., Pasadena, CA. 91103 - License # 197608297 had been relocated to a licensed facility, Glen Park Mariposa, 1220 Mariposa Ave., Glendale, CA. 91205. Additionally, to conduct a health and checks visit regarding the Eaton fire incident on the relocation of (16) residents from a sister facility Bella Vista at Lincoln, 2612 N. Lincoln Ave., Altadena, CA. 91001 - License # 198602253 to Bella Vista 1760 N Fair Oaks Ave., Pasadena, CA. 91103 - License # 197608297 on 1/12/2025. LPA met with Administrator, Ian Baker and explained the purpose of the visit. During the visit, LPA Pena conducted a health and safety check and no concerns observed. LPA reviewed and obtained the resident and staff rosters for both facilities. Per interview with the Administrator (32) residents of Bella Vista Pasadena repopulated on 01/12/2025. (1) resident is still with family members and is expected to be back in the facility tomorrow, 1/16/2025. LPA toured the facility, inspected random residents' bedrooms and bathrooms. LPA observed (2) pallets of water bottles stored near the dining area and extra cases of bottled water in the second floor. LPA interviewed random residents and indicated that they are aware and were instructed not to use tap water. LPA also observed (2) bottles of water were provided in each residents' bathrooms. The facility has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. The kitchen staff will be serving food using disposable plates and utensils. Administrator will be posting signs on the elevator and common areas to remind residents not to use/consume tap water. Medications, MARs, and files of the (16) residents that have been transferred to Bella Vista in Pasadena were brought with them and stored in a secured place. All Bella Vista at Lincoln residents are fully ambulatory, use no assistive devices, and do not require any incontinent care. There is sufficient staffing available to provide care for residents of both facilities. ***Continued on LIC 809-C*** Per the Administrator, Pasadena fire inspectors conducted a walk around fire inspection twice at the facility on 01/12/2025 and 1/14/2025 and was given permission to repopulate. Administrator stated that an Ombudsman conducted the visit at the facility twice, on 1/13/2025 and 1/14/2025. It has been verified that a routine fire inspection and testing was completed on 11/03/2024 and fire drill was conducted with staff on 9/10/2024. Administrator is requesting additional masks and covid testing kits, if available. LPA informed the Administrator to reach out to CCL if any resources or assistance is needed. An exit interview was conducted and a copy of this report was provided to Administrator Ian Baker.the state’s words, verbatim · CDSS document, Jan 15, 2025

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Dec 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 27, 2024

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: 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.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: 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.

Allegation investigated: Facility staff handle residents in a rough manner.

Licensing Program Analyst (LPA) Tena Herrera conducted the initial visit to investigate the above allegations. LPA met with Lizbeth Acuna – Business Office Manager and explained the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of Resident and Staff Rosters, Reviewed Resident #1's (R1) file and gathered copies of Regional Center Individual Program Plan, and Psychiatry Progress. LPA Interviewed Regional Service Coordinator and gathered copies Regional Centers Special Incident Report, Outcome of Incident Report, and Interview Summary Report. LPA interviewed 4 Staff (S1-S4) and 5 Residents (R1-R5). (Continued on LIC9099-C) Unsubstantiated The Investigation Revealed the Following: Allegation: Facility staff handle residents in a rough manner. It is alleged that staff handle R1 in a rough manner as R1 sustained a bruise to left eye, and that S4 does not treat R1 right and has questionable methods. LPA Interviewed Regional Center Service Coordinator that is assigned to R1 and it was explained that S4 is the one-on-one service provider to R1 and during S4's shift on the evening of 11/27/24 R1 was experiencing a behavior and hitting objects in the restroom, as R1 was exiting the restroom R1 bumped their head on the door frame of the restroom hitting the left side of their face, S4 notated the scratch that was observed after the incident and over night the scratch began to bruise. Regional Center conducted an investigation and did not determine any findings as the behaviors that R1 was experience are normal for R1 and R1 has history or unsteady gait causing them to bump into objects or tripping when walking. LPA interviewed S1 and S4 and both confirmed what Regional Center disclosed. S4 denied the allegation and stated that they have never neglected or abused R1, they have been working closely with R1 for over 20 years and this is the first time this has happened, S4 confirmed that this bruise occurred when R1 was experiencing a behavior and bumped into the door frame causing a scratch near left eye, bruising was not present during shift but by next day the bruise appeared in same area that R1 had hit themselves the day prior. S2 and S3 denied the above allegation and stated that they have never observed any staff handle residents in a rough manner. LPA attempted to interview R1 however R1 is has a intellectual disability that prevents successful interviews, LPA observed R1 and R1 was experiencing behavior in which R1 would attempt to hit their head on glass door, S4 was present to block R1 from harming themself. LPA interviewed R2-R5 and each resident denied the above allegation and stated they have never seen any staff handle residents rough or be disrespectful towards residents. Based on statements and interviews conducted with regional center, facility staff and residents, and review of R1's files, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2024 · control 28-AS-20241204095918

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs met with Lynda Whitlock, Receptionist and explained the purpose of the visit. At 9:45am, Administrator, Ian Baker arrived and assisted LPAs with the visit. There are currently thirty five (35) residents 60 years and older residing in the facility. Facility is licensed to serve elderly residents age 60 and above, fire clearance approved for (72) non-ambulatory. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed.  There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has covid-19 digital signage TV screen above the elevator. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Facility is approved for (10) hospice residents, 87705 compliant. A fire clearance is in place. Fire Drill was last conducted on 3/27/2024. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 10/17/2024. Surety bond in the amount of $65,000 is current and expires 12/01/2024. Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: Lobby, Administrative offices, Conference room, Supply room, Power/Telephone room, Kitchen, Janitor room and Elevator. Second floor: (36) resident bedrooms, Medication room, Library, Staff room, Beauty shop, Doctor's office/Nurse station and Dining room. The interior and exterior physical plant was inspected. Kitchen was inspected, knives, sharps objects, cleaning supplies and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. The patio furniture in the backyard did not have umbrellas, but there is an area that provides shade. Laundry area was inspected and one of the washing machines was broken, missing a door.There are cameras without audio in the hallways and common areas. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. LPAs tested hot water temperature in five (5) random resident rooms and water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 95.3 deg F and 119.8 deg F.: Room #8 - sink faucet broken, dripping hot water only Room #9 - observed insects, drain flies in the bathroom Room #20 - 119.8 deg F Room #23 - 105.2 deg F Room #35 - 95.3 deg F, room has no window covering in the bathroom Room #32 - 101.3 deg F Staffing: A total of twenty seven (27) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records/Staff Training: LPA reviewed four (4) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator Ian Baker's certificate expires on 01/12/2025. Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. LPAs observed the activities calendar posted in the activity room. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Incidental Medical and Dental: Four (4) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Resident Records/Incident Reports: Resident files are maintained at the facility. A total of four (4) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Fire drill is conducted on a monthly basis and last fire drill was conducted on 03/13/2024. Residents with Special Health Needs: Half bed rails for mobility assistance were observed in some resident beds. LPAs observed 1/2 bedrail in C2's bedroom and facility cannot provide a written order from C2's physician. "Oxygen In Use" signs were posted on the resident doors who are using oxygen. Deficiencies issued on LIC809-D. An exit interview was conducted, and a copy of this report was provided to Greg Tillman, Administrative Assistant along with the Appeals Rights.the state’s words, verbatim · CDSS document, May 9, 2024