Bella Vista

Allegation: Staff do not ensure resident’s privacy. The reporting party (RP) stated that at night around September 2025, resident (R1) was going to the big building in the facility to take a shower, and R1 observed staff (S2) giving bath to resident (R2). R2 was naked and the bathroom door was open while S2 was giving R2 a bath. All residents except R1 stated not observing any staff giving bath to residents with bathroom door open. R1 stated observing S2 giving bath to R2 one night with bathroom door open. One of the staff does not provide care giving while the other one stated not providing assistance with bathing to residents. S2 who works NOC shift stated he does not give bath to residents including R2 at night and that residents are given bath during the day. The rest of the staff interviewed indicated when they provide assistance with bathing they close the bathroom door. Due to medical condition, LPA was not able to obtain information from R2. Therefore, the allegation is close as unsubstantiated. Allegation: Staff are not meeting residents’ dietary needs. The reporting party (RP) stated R1 has been forced to eat meat but due to religion, R1 cannot eat meat or use animal products due to R1 itches when eating and/or touching animal products. Review of records showed R1 was seen by a doctor due to itching but After Visit Summary didn’t indicate to avoid and/or not eat animal products. LIC602A Physician’s Report didn’t indicate any food allergies or other type of allergies. On 10/07/25, R1 stated that when he moved-in, he told the staff that he prefers vegetarian food but he turned vegan around 10/2025, because whenever he eats something with meat and meat bi-products, he itches. At first, the staff told him 'maybe' and later was offered vegetarian diet but it's not totally vegetarian because they still put meat on it. Around first week of October 2025, the cook told him he can buy his own food and the cook will prepare for him b ut S7 told him that he should no t be bothering the cook which S7 denied telling R1. ........continued on 9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 11/04/25, R1 stated the staff are good and serving him vegetarian meals. LPA conducted inspection of the kitchen and observed list of residents who are on soft diet and those with food preference but no list of residents who are vegetarian or vegan. The cook stated he does not have list but he knows because there's only 2 of them. He stated R3 is vegetarian due to religious/spiritual belief and he does not serve R3 meat. He further stated that he himself is vegetarian, so whatever he prepares for himself, he serves to R3. He also stated that R1 use to eat meat before but around September 2025, R1 transitioned to vegan. On November 2025, R1 told him that he's not eating meat so he prepared him vegetarian meals for about 5 days, but after 5 days, R1 told him that vegetarian diet is not working, so R1 started eating meat again and asked him for hot dog. When R1 told him he is vegan, he served him vegan meals. R3 stated staff do not served him meat. Based on interviews and records review, the allegation is unsubstantiated. Allegation: Staff do not ensure residents are accorded dignity. The reporting party (RP) stated that when staff (S3) was putting 'apron' on resident's (R2) thigh while in the dining room during meal, S3 touched R2's thigh and was not mindful. R1 stated it bothered him and does not think that the touching was accidental. S3 confirmed she puts an apron like a bib and ties it on R2's neck and the apron stretches up to the lap. S3 denied touching R2's thigh when placing the apron. Due to medical condition, LPA was not able to obtain information from R2. Therefore the allegation is unsubstantiated. Based on interviews, records review and inspection, the 3 allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

On October 2025, the reporting party (RP) stated that R1 reported a staff, S1, had punched R1 in the head with closed fist two times and grabbed the neck of R1's shirt and pulled R1. R1 further reported that S1 yelled at R1 and threatened to "beat him up". The administrator (ADM) stated that one of the staff reported to her that a police officer came due to the reported abuse. S1 was interviewed by the police officer and asked if R1 went out and fell outside the facility and interviewed S1 regarding the alleged abuse which S1 denied. ADM submitted a copy of SOC341 to the Department. SOC341 also indicated that on 9/22/25, R1 was 5150'd due to pulling of the hair of one of the staff. S1 denied the allegation. He stated the police officer came and he was not aware there's a complaint by R1 against him. He was asked if R1 went out that day and he told the police officer he does not know, because the residents can leave the facility. There were times when R1 left the facility at night and tell other residents when he leaves and S1 did room check. He was also asked if he ever hit R1 and he said he never did and that he's here to assist the residents. The other staff interviewed stated not observing S1 being physically and/or verbally abusive to R1. Some of these staff stated it is them who are at times hit by residents. The 4 residents (R2, R3, R4 and R5) stated not observing staff including S1 being physically and verbally abusive to R1. They stated S1 is a good staff. Review of 3 Unusual Incident Reports (UIRs) for incidents that happened on October 2025 showed R1 had 2 unwitnessed falls and an episode of seizure where R1 was sent out to the hospital. The hospital After Visit Summaries confirmed the incidents and one of these documents showed R1 sustained laceration of the scalp Based information gathered and due to R1 was no longer at the facility when LPA began the investigation, the above allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

While at the facility investigating a complaint (Control # 15-AS-20251007084713) and upon review of resident's (R1) file, Licensing Program Analyst (LPA) Delmundo observed 3 Hospital Discharge Summaries showing R1 was seen in the hospital due to fall incidents that happened this October 2025. LPA interviewed Haidie Bautista, administrator (ADM), who stated she sent Unusual Incident Reports (UIRs). LPA checked the Department's e-faxed documents and facility's e-fax folder and didn't see UIRs for the said incidents. LPA also learned from ADM that local law enforcement came to the facility October 2, 2025 due to an alleged abuse, and LPA has not receive the SOC341 nor the UIR from the facility. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Deficiencies were discussed with the administrator, and informed that any repeat violations within 12 month period may result in civil penalty. Exit interview conducted. Appeal Rights and copy of this report provided.

While at the facility investigating a complaint (Control # 15-AS-20230705170957), and upon review of Facility Notes and interview, Licensing Program Analyst (LPA) Delmundo learned and observed the following: 1. Resident (R1) AWOLed on December 26, 2022, and according to Haidie Bautista, administrator, during interview on this day, July 11, 2023, she did not submit Unusual Incident Report to the Department. 2. Residents (R1 and R2) exhibited behaviors. R1 was at John George for 3 months and was discharged back to the facility on June 21.2023. These 2 residents do not have Pre-Admission Appraisal nor Re-appraisals. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies plan and proof of correction were discussed with administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Facility Type: CHOFT Application Type: RCFE Capacity: 42 Census (if any clients in care): 13 Method: Telephone call with CAB Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant /administrator was verified by correctly answering identity verification questions. During COMP II, applicant/administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

During the course of investigation, the Department obtained copies of LIC9020 Register of Facility Clients/Residents, staff roster and LIC624 Unusual Incident Report concerning resident (R1). Copies of R1’s following documents were also obtained: LIC602A Physician's Report; Preplacement Appraisal; LIC625 Appraisal/Needs and Services Plan; LIC9172 Functional Capability Assessment. Local law enforcement was also involved in the investigation and copy of police report was obtained and reviewed. The following were interviewed: RP on 6/09/25; staff (S2, S3, S4) and administrator (ADM) on 6/10/25; residents (R2, R3, R4) on 6/10/25; resident (R1) on 6/16/25; staff (S1) on 6/19/25. RP confirmed what R1 reported to RP. RP stated that R1 told RP about S1 telling R1 not to tell anyone what had happened. S1 asked R1 for R’s phone number as S1 said he was leaving the facility and wanted to keep in contact with R1 but R1 did not provide S1 with R1’s phone number. R1 was inconsistent with her statement to the Department. R1 stated that S1 gave R1 “a quick kiss” only and that there was no other inappropriate touching, and no part of S1’s body parts touched R1’s back. The Hayward Police Department closed their case due to R1 not wanting to make a statement. S1 denied all allegations of inappropriate touching. S1 stated he has showered and dried R1 multiple times without incident. S1 further stated that he has never said or done anything to upset R1 that would prompt this type of allegation, did not notice any changes in R1’s behavior during the week of the alleged incident, and R1 has never indicated that R1 was uncomfortable around him. The staff and residents interviewed said they never saw S1 act unusual or inappropriate around residents or R1. There were no staff or residents who could have witnessed the incident. The information gathered during investigation did not confirm the allegation, therefore the complaint is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that there is not a preponderance of evidence to prove that the allegation and violation occurred. No deficiency cited. Exit interview conducted and a copy of this report provided.

. . . Continued from LIC 9099 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED . Exit interview conducted and a copy of this report was provided.

On 4/21/2025, at 12:45 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a case management health and safety check as a result of a complaint (15-AS-20250417163152) received by the Department. The LPA met with Administrator Haidie Bautista and informed her of the reason for the visit. The LPA toured the interior and exterior of the facility with the House Manager (HM) Sally Estina. During the tour, the LPA observed the kitchens, dining rooms, living rooms, bedrooms, bathrooms, smoking area, and shared yard for both houses at 1641 and 1659 D Street. No citations were issued during the inspection. Exit interview conducted and a copy of this report was provided.

Page 2 All 5 staff interviewed provided information on food/meal serve which were of different varieties. They serve corn dog only once or 2x a week. One out 3 residents interviewed provided information consistent with the information provided by the staff. One of the other resident stated food served is always good while the other one does not remember but not have issues/problems on the meals provided. Two other residents refused to be interviewed. ADM stated she does the grocery shopping online of different varieties from different grocery chains and whatever is not available she asks one of the staff to do in-person grocery shopping. LPA inspected the food supplies and copies of menus showed different varieties. Based on inspection and interviews and LPA unable to obtain information from 2 residents, the allegation is closed as unsubstantiated. Allegation: Facility staff are restricting resident's telephone use. LPA conducted inspection and observed both buildings with land line telephones. All 5 staff stated the residents are allowed to use the facility telephone. Two of these staff and ADM stated that for courtesy to other residents who also want to use telephone, they tell the residents to limit their calls to 10 minutes but they can come back to use the telephone again. One of the 5 staff and ADM also stated that the facility also gets incoming calls and at times may need to make emergency calls. One of the 3 residents stated not using the facility telephone because this resident has cell phone. The other 2 residents stated they are allowed to use and not told to limit their calls. The other 2 residents refused to be interviewed. Based on interviews, the allegation is unsubstantiated. Allegation: Facility staff are restricting resident's leisure time activities. RP stated that all electrical devices such as TV, radio, etc, have to be off at 9:00 p.m. to save electricity, even if they are used with a headset. .....continued on 9099 (page 3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 3 During inspection, LPA observed residents in both buildings watching TV, while others doing activities coloring book in the dining area. All 5 staff interviewed stated residents are allowed to watch TV as they want. The TV is turned off at night when observed no resident is watching. ADM denied telling the residents to turn off the TV, radio or other electrical device at 9:00 pm to save on electricity. She only tells them to turn down and/or use headset. One out of 3 residents stated they are allowed to watch tv and staff ask to turn off at 8:00 pm but this resident stated still watches TV after 8:00 pm. One of these 3 stated residents are required to turn off the TV at 8:00 pm which is okay with this resident. The other resident stated staff allow them to watch as they want. LPA tried to interview the other 2 residents but they refused. Therefore, the allegation is unsubstantiated. Based on interviews and observation during investigation, the allegations are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted, and copy of this report provided.

While at the facility conducting investigation of a complaint (Complaint Control # 15-AS-20260305094639) on this day, March 11, 2026, and upon review of resident's (R1) record, Licensing Program Analyst (LPA) Delmundo observed one of R1's medications which was filled on February 10, 2026 with 84 tablets and administered 3x/day, with start date of administration February 10, 2026, showed this particular medication still has one remaining tablet. Staff (S1) who administers residents medications was not able to explain what happened why there is still one remaining tablet. This was discussed with Haidie Bautista, administrator (ADM), who stated that it could be a recording error. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and plan and proof of correction were discussed with ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo conducted Component III Training via Teams Meeting. Component III was attended by Haidie Bautista, applicant-administrator. LPA Delmundo presented the training via Power Point presentation and had a discussion with Haidie Bautista. Exit interview conducted and copy of this report provided at the conclusion of the training.

Licensing Program Analyst (LPA) Delmundo conducted pre-licensing inspection. License application is for fourty two (42) total capacity, of which twenty six (26) may be non-ambulatory. Fire clearance was granted on August 8, 2022. Application is for change in facility type to Residential Care Facility for Elderly (RCFE) and facility is currently in operation. LPA called and spoke with Haidie Bautista who authorized Sally Espina, staff, to be with LPA during inspection. Applicant arrived after about 20 minutes. LPA started the inspection with Sally Espina and continued with Haidie Bautisa. The facility comprises of two buildings. The main building will house the non-ambulatory. There is no body of water. LPA inspected the 2 buildings including but not limited to living rooms, dining areas, kitchens, bedrooms, bathrooms, shower rooms, front, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed sufficient good for seven days of non-perishables and 2 days of perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinets were knives, and medication carts and cabinets were medications are centrally stored were observed locked. Toliets and bathrooms/showers were observed equipped with grab bars and non-skid mats. Complaint poster, Ombudsman and Personal Rights posters, Rights to Resident Council and Rights to Family Council were observed posted in the prominent place. A central screening station for staff and visitors were observed set-up by entrance door in the 2 buildings. Facility has central storage for PPEs and observed adequate for 30 days. Facility's Infection Control Plan with Monkeypox Addendum were submitted by applicant and received by LPA on 10/18/2022. .....continued on 809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Fire extinguishers checked and observed fully charge with tags showed serviced February 2, 2022. Carbon monoxide and smoke detectors operational. First aid kit inspected. Facility has flash lights for emergency lighting. Hot water temperature in one of the common bathrooms was tested. Facility has land line phone which is in operating condition. LPA observed the following: 1. No auditory alarms on all entrance and exit doors. 2. No signal system on both buildings and no call buttons for residents' use. 3. Hot water temperature was measured at 122 degrees Fahrenheit. 4. Beds have no mattress pads. Staff put mattress pads on the beds while LPA was at the facility. 5. No "Wear Masks" posters in common areas, dining room and activity room. Applicant posted posters while LPA was at the facility. 6. Facility's Theft and Loss Policy not posted. Applicant posted the document while LPA was at the facility. Copy of staff's current N95 Fit Testing certificates and $3M liability insurance certificate submitted to LPA on this same day. LPA reminded applican t of u pdating residents and staff files to reflect facility name and number once license is granted. LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application and license to be granted by CAB analyst. Exit interview conducted and copy of this report provided to Haidie Bautista.