Bella Vista Village II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Jessica Vegvary, licensee and Administrator arrived later, Administrator Certificate 7028206740 expires 5/16/28. Facility currently has eleven (11) residents in care two (2) of which are currently on hospice. At approximately 9:45am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled with opened dates present. LPA observed kitchen cabinet under sink to contain disinfectants and cleaning supplies. Cabinet has magnetic locking mechanism. All other cleaning products and laundry soaps are located in the laundry room and inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 108.3 degrees F in cottage #3, 109.5 degrees F in cottage #2, 104.4 degrees F in cottage #1, and 107.4 degrees F in the main house. Licensee will continue to monitor water temperature to ensure that water stays at a temperature within regulation. The allowable range is between 105 to 120 degrees F. Fire extinguishers were last inspected 8/17/26. Smoke/Carbon Monoxide detectors were tested and operational. Facility’s last quarterly disaster drills were conducted in June and July 2026. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809... At approximately 11:30am LPA conducted a review of ten (10) out of eleven (11) resident files. No deficiencies cited. At approximately 1:00pm LPA conducted a review of five (5) staff records. No deficiencies cited. LPA discussed with licensee Health and Safety Codes (HSCs) 1569.69 and 1569.625. LPA advised of subject matters required for medication training per HSC1569.69 (a)(4)(A-I). LPA also discussed with licensee HSC1569.69(a)(7) which states that "the training requirements of this section are not intended to replace or supplant those required of all staff members who assist residents with personal activities of daily living as set forth in Sections 1569.625 and 1569.696." Additionally, LPA discussed with licensee HSC1569.69(b) which states that "Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period." At approximately 2:00pm LPA and licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. LPA and licensee discussed items with active ingredients are best to be centrally stored. No deficiencies cited. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance No deficiencies cited during this inspection. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Jessica Robles. Administrator Certificate # for Jessica Robles is 7028206740 and expires 5/16/26. Facility contact information was reviewed. At approximately 10:00am LPA and Admin toured the building and grounds. While touring the facility LPA observed caregiver engaged in sensory activities with residents in the Main house. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and most items had date of opening marked on containers. Kitchen drawer with sharp knives locked. Cabinet containing cleaning supplies was locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 113.9 degrees F in the kitchen, 107.6 degrees F in cottage #3, 107.3 degrees F in cottage #2, 108.1 degrees F in cottage #1, and 109.7 degrees F in Main cottage which are all within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 8/5/24, but are showing as fully charged. Smoke/Carbon Monoxide detectors located throughout the facility are serviced by a vendor, last date of service was March 2025. Facility’s last quarterly disaster drills were conducted on 6/10/25, 6/12/25. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809... At approximately 12:00pm LPA conducted review of six [6] staff records. S1 did not have a Health Screen on file (deficiency cited, see 809D). At approximately 1:30pm LPA conducted a review of six [6] resident records. Resident (R1) had razors accessible but on their physician's report it states that "at risk if allowed direct access to personal grooming and hygiene items." Per Admin, R1 likes to be independent as possible with grooming so Admin will continue to have caregiver present at all times while R1 is using grooming razors but will now keep razors in locked cabinet. 1/2 rails and crushed meds orders all on file for respective residents. R1 did not have clear TB result on file, however R1 did have a chest xray on file, but results not listed that Admin or LPA could find. Admin called to get clear TB screen with LPA present. At approximately 2:30pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. LPA advised Admin that all PRN and prescription medications must be listed on the Centrally Stored Medication Log (CSML). If a medication, PRN or otherwise, is no longer being administered, there must be a discontinuation notice on file. LPA and Admin discussed ensuring most current physician's orders are maintained on file. LPA and Admin discussed ensuring all instructions for medications be listed on CSML, even if a PRN. LPA and Admin discussed live pouring medications as they may not be pre-poured. Admin agrees to cease pre-pouring medications. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 19, 2025

The state marks this report as 9 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: 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

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 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)... 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).the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 21-AS-20240801142746

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Nov 14, 2024

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. 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.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: 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.

Type of visit: Case Management - Deficiencies

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... 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).the state’s words, verbatim · CDSS document, Nov 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 21, 2024

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, 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.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Jessica Robles arrived later. Facility contact information was reviewed. At approximately 10:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food items were found to be uncovered in the refrigerator such as watermelon, grains and cereals in canisters without dates of filling/opening, and canned and boxed goods found with expired best if used by dates: various brands of peanut butter with best if used by dates of 8/28/2023,12/7/2023, 5/15/2024, and 1/16/2024; canned mini raviolis with best if used by date of 6/5/2023; box of Rice a Roni with best is used by date of 2/14/2024; can of Manwich with best if used by date of 11/22/2023 (deficiency cited, see 809D). Kitchen cabinet containing cleaning supplies was not locked, however cabinet is located behind baby gates. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. LPA and Admin observed bedroom #1 in Memory Care main house found to have strong urine smell, per Admin the urine smell is from the mattress. Shared room in cottage #2 had a bed that smelled strongly of urine (deficiency cited, see 809D). Bedroom #4 had broken wall outlet cracked and missing the right side portion of face plate and internal box visible. Extra hygiene products and linens were available. Half bath in Memory Care main house did not have working fan or lights, switches did not work (deficency cited, see 809D). All other resident bathrooms had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 117.3 and 111 degrees F which is within the allowable range of 105 to 120 degrees F. Continued on 809C... Continued from 809... One [1] out of five [5] fire extinguishers were last inspected 3/5/2024 and four [4] out of five [5] fire extinguishers were last inspected 8/5/2024. Carbon Monoxide detectors were tested and operational as indicated by Fire Marshall sticker by fire alarm in March of 2024. Facility has a backup generator for use during a power outage LPA conducted a review of 5 resident records. Three [3] out five [5] residents R1, R2, and R3 did not have a current appraisal and R1 has a diagnosis of dementia but their most recent physician's report is dated 5/10/2023 (deficiencies cited, see 809D). LPA conducted review of 6 staff records. Five [5] out of [6] staff, S1, S2, S3, S5, and S6 did not have current annual training completed (deficiency cited, see 809D). S6 did not have fingerprint clearance and was not associated to the facility. Per Guardian, S6 fingerprint application was received 3/29/2023 and closed for incomplete application on 6/27/2023. Reasons listed were #8, #9, and #20 (deficiency cited, see 809D and *civil penalty assessed*). LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. No deficiencies Jessica Robles Administrator Certificate 7028206740 expires 5/16/2026. All fees are current as of this time.. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report, LIC308- Designation of Responsibility, and Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 6, 2024

The state marks this report as 10 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Chris Arnhold and Christi Coppo arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Jessica Robles. There were two care givers on duty to provide care and supervision for eleven residents. Facility currently has three residents on hospice which is allowable per the facility's Hospice Waiver for six. LPAs and Administrator initiated a tour of the facility around 9:20am and made the following observations: Facility was a comfortable temperature. Passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sink accessible to residents in care measured at 106 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Medications are secure. Kitchen cabinet containing cleaning supplies was located behind 2 baby gates. Facility has at least two days of perishable and seven days of non-perishable foods. Fire extinguishers were last inspected August 10, 2023. Carbon Monoxide detectors were tested and operational as indicated by Fire Marshall sticker by fire alarm on March 2023. Facility was recently inspected by the local fire department and no issues were noted regarding fire alarms. Last quarterly disaster drill conducted 8/20/2023. Three staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Jessica Robles 6063077740 expires 05/16/2024. Medications and medication records were reviewed. Medication record for (R1) had two errors, Systane eye drops were not listed in the correct quantity and Prednisolone eye drops was not on the CRM. Training records were reviewed. Required postings were observed in the kitchen. LPAs confirmed that facility has valid Liability Insurance. Licensee/Administrator to submit updates of the following documents by 10/30/2023: LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (If changes) LIC 308 Designation of Facility Responsibility Liability Insurance Infection Control Plan- need recently updated plan No deficiencies were observed in the areas inspected. No citations issued during today’s visit. .the state’s words, verbatim · CDSS document, Oct 16, 2023

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.