197604333-10-21-2022-29-AS-JAPL-CL6UNX-20221114144437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604333
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:55:06 AM

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
09/26/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220926125500

FACILITY NAME:	BELLA ROSA PLACE, LLC.		FACILITY NUMBER:	197604333
ADMINISTRATOR:	JOLANTA ROBERTS		FACILITY TYPE:	740
ADDRESS:	23275 SYLVAN ST		TELEPHONE:	(818) 625-0517
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jolanta Roberts		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

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Facility staff does not assist resident with the self-administration of their medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent visit to deliver the findings for the above allegations. The LPA met with Staff Evangelina “Eva” Zinampan and spoke to Administrator Jolanta Roberts over the phone and explained the reason for the visit. The administrator Jolanta Roberts arrived at 12:00 p.m. to sign the report.

During the visit on 10/3/2022, the LPA conducted a physical plant tour at 9:55 a.m., interviewed Residents at 10:05 a.m., 10:42 a.m., 11:05 a.m. and 11:06 a.m., interviewed staff at 10:45 a.m., 12:40 a.m. and 3:20 p.m., reviewed documents and records at 11:15 a.m. and 12:20 p.m. Interviewed responsible parties at 12:52 p.m. and 2:16 p.m. Collected pertinent documents at 4:00 p.m. During today’s visit, the LPA conducted a physical plant tour at 9:35 a.m., reviewed resident files at 9:55 a.m., interviewed resident at 10:30 a.m. and interviewed staff at 11:00 a.m.

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: 10/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220926125500

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: 10/21/2022

NARRATIVE

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Regarding the allegation: Facility staff does not assist resident with the self-administration of their medication as prescribed.

It was alleged that staff failed to assist resident with the self-administration of medication as prescribed. The complainant’s concern was that residents of the facility were once able to keep their vitamins in their possession and are no longer able to do so. The LPA conducted a sample inventory of medications and reviewed the required documentation in reference to the medications that were alleged to kept by R1, record review confirmed that all over the counter medications and prescribed medications were accounted for and kept locked by facility staff. An interview with Resident #1 (R1) revealed that they used to be able to keep over the counter supplements with them. A review of R1’s physician report indicated that R1 is not able to store or administer their own medications. R2 and R3 denied ever keeping their medications or over the counter medications in their possession. In speaking with R1, R1 claimed that they take vitamins and they order their own vitamins, but the facility keeps them. The LPA spoke to R1 and R1 claimed that they do not have any of their medications with them and if they did, they would be taken away anyway. At the time of visit no medications were observed to be in their possession. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to assist R1 with the self-administration of medication. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited regarding 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: 10/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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