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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802266
Report Date: 08/04/2026
Date Signed: 08/04/2026 01:02:46 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/30/2026 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20260730084809
FACILITY NAME:BELLA VITA ASSISTED LIVINGFACILITY NUMBER:
405802266
ADMINISTRATOR:TESFAZGY, ABIYFACILITY TYPE:
740
ADDRESS:7150 SYCAMORE ROADTELEPHONE:
(805) 460-6883
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 5DATE:
08/04/2026
UNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Abiy TesfazgyTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff does not ensure facility has adequate supply of perishable food for residents in care
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20260730084809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLA VITA ASSISTED LIVING
FACILITY NUMBER: 405802266
VISIT DATE: 08/04/2026
NARRATIVE
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2