197604333-12-14-2021-29-AS-JAPL-C9QURR-20211215144909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604333
Report Date: 12/14/2021
Date Signed: 12/14/2021 02:30:52 PM

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
12/13/2021 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20211213161835

FACILITY NAME:	BELLA ROSA PLACE, LLC.		FACILITY NUMBER:	197604333
ADMINISTRATOR:	FOLAYAN, GBOLABO		FACILITY TYPE:	740
ADDRESS:	23275 SYLVAN ST		TELEPHONE:	(818) 625-0517
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	12/14/2021
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Feesperanz Pineda		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not provide residents with hygiene supplies.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPA’s) Elsie Campos and Ashley Smith conducted an unannounced complaint visit to the facility today. The LPA’s met with caregiver Feesperanz Pineda explained the reason for the visit. There was one staff and five residents present. The LPA's spoke with the Administrator Jolanta Roberts who was unable to come to the facility.

Today, the LPA's conducted a tour at 10:15 a.m, interviewed staff at 10:17 a.m.,10:20 a.m. and 12:43 p.m.; interviewed residents at 10:31 a.m., 10:39 a.m. and 1:40 a.m. and reviewed records at 10:48 a.m.

Regarding the allegation it was alleged that the facility was without toilet paper for three days. Staff interviews revealed that the facility has always had toilet paper and if need be can order supplies. The administrator along with other staff are responsible for obtaining supplies for the facility. During the tour LPA’s observed toilet paper in the supply closet and in all bathrooms.

,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 29-AS-20211213161835

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 ROSA PLACE, LLC.	FACILITY NUMBER: 197604333
	VISIT DATE: 12/14/2021

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
26
27
28
29
30
31
32

Discrepancies were shared as to whether the facility was without toilet paper. Initially, residents negated claims that the facility was out of toilet paper for three days. In addition, residents were unable to confirm a time when they were without toilet paper. Later in the investigation, one resident claimed that they did not have toilet paper, however staff claimed the facility always had toilet paper.

Based on the investigation there is insufficient evidence to support the claim that the facility does not provide residents with hygiene supplies. This allegation is deemed unsubstantiated at this time.

No deficiencies cited regarding the complaint. Case management visit issued to address deficiencies cited during today's visit which are unrelated to the complaint.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
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

LIC9099 (FAS) - (06/04)

Page: 2 of 2