Bella Vita Assisted Living

Allegation investigated: Staff does not ensure facility has adequate supply of perishable food for residents in care

Licensing Program Analyst (LPA) De Leon conducted a 10-day Complaint visit to the facility above. LPA was greeted by staff that called Administrator. Administrator arrived shortly after. LPA toured facility kitchen and garage food supply, the facility had a supply of fresh fruit as well as canned and packaged fruit. LPA spoke with 4 residents in care at the lunch table eating and 4 residents replied and said they get plenty to eat everyday, fruit is served with every meal and they get served food they like and eat. A witness had visited the facility on 07/29/2026 and there was only fresh fruit of 1 apple and 1 orange for 5 residents in care. LPA interviewed staff that stated we were low on fresh fruit last week but that same day the Administrator had done shopping and brought us a large supply of fresh fruits to the facility. Staff stated they have another refrigerator and Non perishable food in the garage. The canned/packaged food in the garage had a very large supply of fruit and vegetables. The 2 days of perisables can consist of any type of perishable food at the facility and it is not rerquired to be all fruit. Continued 9099-C Unsubstantiated Staff stated if anything is needed staff can ask the Administrator to bring it to the facility and the Administrator does bring whatever is needed when staff ask, it has never been an issue. LPA took photographs of the full food supply at the facility. The packaged fruit, canned fruit, and the fresh fruit was more than enough servings for 5 residents in care to cover the regulation requirement of 2 days perishable food and 7 day non-perishable food. If the facility was low on 1 day last week of fresh fruit the facility had canned and packaged fruit that would meet the servings requirement for 5 residents in care. The facility had a supply of emergency food stored in containers in the garage. Based on a lack of evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 29-AS-20260730084809

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 11:50am to conducted a 1 year annual visit to the facility above. LPA met with Staff Paraluman Tatsuo, whom called Administrator. Administrator Abiy Tesfazgy arrived shortly and LPA explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) initially and annually thereafter. Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 12/01/2025. The facility is approved for a capacity of 6 with 6 Non-Ambulatory. Hospice approved for 2. Physical Plant & Environmental Safety: The facility is a 4 bedroom and 2 bathrooms currently occupying 3 residents and employs 3 full time staff and 1 Administrator. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has an fenced backyard for client use with plenty of shade. The gate on the sides of house are self closing and self latching. The facility has telephone and internet service for resident use. Continued 809-C Staffing: The facility employes 3 full time staff and 1 Administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator Certificate expires 09/2027. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have training with 20 plus hours meeting topics to cover for 2024-2025. Required forms are present. Residents Rights and Information: All required personal rights are posted. CCL and LTCO Complaint posters are posted. Emergency Plan, Licnese, Non-Discrimmination is posted in the common area of the facility. The facility offers telephone and internet service to residents in care. Planned Activities: The facility has an acitvity calendar, puzzles, games, books and TV. There is enough space inside and outside for activities. Residents do the activities they like and want to do. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices. Incidental Medical and Dental Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA checked medications for all 3 residents, medication labels were not altered, medications were stored in original containers and no expired medication was found. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 3 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible and completed in separate confidential binder for each resident in care. Continued 809-C Disaster Preparedness: The old emergency disaster form was posted. Administrator updated the current version and posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and last inspected on 11/20/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care in laundry room. The facility has 1 resident currently on oxygen and a sign is posted. The facility does not currently have any hospice residents in care. Hospice care plans are kept on file and up to date when needed. The facility currently has 2 residents receiving Home Health services. Home Health services records are kept on file. The facility does not have delayed egress. Exit doors have alarms. LPA interviewed 2 staff and 2 residents. Administrator had to leave the annual early and authorized staff to sign report. Exit interview conducted, copy of report printed for facility.the state’s words, verbatim · CDSS document, Nov 6, 2025

The state marks this report as 34 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At 8:30 am on 10/17/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual inspection visit. LPA met with Licensee Abiy Tesfazgy, announced who he was and the reason for the visit. LPA toured facility to note the facility is maintained in conformance with state fire marshal regulations. smoke detectors and carbon monoxide detectors functioning throughout the facility. Fire extinguisher was fully charged. This facility has a water sprinkler system in its roof and water pressure tested in December 23, of 2023 by Atascadero Fire Safety. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 72 *(f). Hot water temperature tested and read within regulation parameters. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed two days of perishable and seven days of non-perishable food. A written disaster and mass casualty plan is readily available located on the kitchen wall. Medications are stored in a locked cabinet in the kitchen. LPA reviewed resident and staff files. LPA noted that this a 4 bed room and two bathroom facility with two rooms for double resident occupancy and two rooms for single resident occupancy. LPA noted that there are two living rooms, a dining room and kitchen.There is a covered patio in the back that is screened to provide residents shade for outside activities. LPA noted that the laundry room did not have a door and the locked cabinet on the right side of the laundry room was not functioning and chemicals were readily accessible to residents in care. Licensee and LPA conduced a full review of the care tools module. LPA noted that Community Care Licensing (CCL) regulation 87309(a) was cited as noted in report above in the care tools modules. LPA noted that no other citations, violations, technical were issued in this full annual inspection. Exit interview, report read, appeal rights, and report provided.the state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: Required - 1 Year

At 9:30 am on 11/06/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual inspection visit. LPA met with direct care staff Jackie Tatsuo (S1), announced who he was and the reason for the visit. S2 called Licensee Abiy Teafazgy by phone, Licensee was out of town shopping for facility grocery's and gave verbal permission to LPA to conduct annual visit with S1. LPA toured facility with S1. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning throughout the facility. Fire extinguisher was fully charged. This facility has a water sprinkler system in its roof and wes pressure tested in December of 2022 by Atascadero Fire Safety. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 72 *(f). Hot water temperature tested and read within regulation parameters. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed two days of perishable and seven days of non-perishable food. A written disaster and mass casualty plan is readily available located on the kitchen wall. Medications are stored in a locked cabinet. LPA reviewed resident and staff files. LPA discovered that 4 of 5 residents have been identified with a diagnosis of Dementia by prior Physician reports (LIC602's) and/or Appraisals Needs and Services Plans whose Physicians reports are over 12 months since last LIC602 was completed. LPA addressed those deficiencies in annual care tools specific to those violations. LPA noted that the facility was clean and in good repair. LPA conducted a full annual care tools review. LPA noted and cited on 4 residents not having a current LIC602 according to their individual diagnosis. LPA contacted the Licensee by phone and addressed the violation with a plan of correction on this citation. LPA noted that no other citations, violations, technical were issued in this full annual inspection. Exit interview, report read to S1 and report provided.the state’s words, verbatim · CDSS document, Nov 6, 2023