<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604333
Report Date: 12/14/2021
Date Signed: 12/14/2021 02:19:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELLA ROSA PLACE, LLC.FACILITY NUMBER:
197604333
ADMINISTRATOR:FOLAYAN, GBOLABOFACILITY TYPE:
740
ADDRESS:23275 SYLVAN STTELEPHONE:
(818) 625-0517
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 5DATE:
12/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Feesperanz PinedaTIME COMPLETED:
02:00 PM
NARRATIVE
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
Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20211213161835.

During today’s investigation, the LPAs observed cleaning items accessible in the bathroom through the garage. At 10:18 a.m., the LPAs observed unsecured laundry detergent and cleaning supplies in the laundry room through the garage. At 10:21 a.m., the medication cabinet in the kitchen cabinet was unlocked. At 10:23 a.m., sharp objects were observed accessible in the kitchen drawer. At 10:25 a.m., the LPAs observed over-the-counter creams and ointments observed in an unlocked hallway closet.

During the records review conducted at 10:48 a.m., the following was noted: five out of five residents (R1, R2, R3, R4, R5) require an updated or completed appraisal. Two out of five residents (R1, R2) need an updated medical assessment due to their diagnosis of dementia. The LPAs observed bedrails, yet the file review determined that two out of three residents require an order for the bedrails.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, today's reports and appeal rights were reviewed and issued. The Administrator authorized staff to sign the report.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 ROSA PLACE, LLC.
FACILITY NUMBER: 197604333
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2021
Section Cited

1
2
3
4
5
6
7
87705(f)(1) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above, as sharp objects were accessible, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
12/15/2021
Section Cited

1
2
3
4
5
6
7
87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins .... toxic substances such.. cleaning supplies and disinfectants. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above, as over the counter medications and cleaning supplies were accessible, which poses an immediate health and safety risk to residents in care.

8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 ROSA PLACE, LLC.
FACILITY NUMBER: 197604333
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2021
Section Cited

1
2
3
4
5
6
7
87608(a)(3) Postural Supports. A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on record review, the licensee did not comply in the section cited above, as two out of five residents (R3, R5) requires an order for use of a bedrail, which poses a potential health and safety risk to residents in care.


8
9
10
11
12
13
14
Type B
12/28/2021
Section Cited

1
2
3
4
5
6
7
87705(c)(5) Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on record review, the licensee did not comply in the section cited above, as five out of five residents need an appraisal, and two out of five residents (R2, R4) need a medical assessment, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3