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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604333
Report Date: 01/23/2023
Date Signed: 01/23/2023 06:37:47 PM

Substantiated


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
06/13/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220613110952
FACILITY NAME:BELLA ROSA PLACE, LLC.FACILITY NUMBER:
197604333
ADMINISTRATOR:JOLANTA ROBERTSFACILITY TYPE:
740
ADDRESS:23275 SYLVAN STTELEPHONE:
(818) 625-0517
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
01/23/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Manjit 'Mani' ChadhaTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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9
Staff did not provide a safe environment for residents in care
Resident sustained falls while in care
INVESTIGATION FINDINGS:
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3
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5
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7
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9
10
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13
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 Manjit ‘Mani’ Chadha over the phone who arrived shortly thereafter and explained the reason for the visit.

On 6/20/2022 Licensing Program Analyst's (LPA's) Elsie Campos and Ashley Smith conducted an unannounced initial complaint visit to the facility. The LPA met with caregiver Feesperanz Pineda explained the reason for the visit. There was two staff and five residents present. The LPA spoke over the phone with the Administrator Solomon Gochin who arrived at the facility shortly thereafter. The LPA’s conducted a plant tour at approximately 9:45 a.m., interviewed staff at 10:02 a.m., 10:20 a.m., and 2:35 p.m., interviewed residents at 11:15 a.m., 11:21 a.m., 11:28 a.m., 11:29 a.m. and 11:55 a.m., conducted a file review at 11:45 a.m., and completed a medication audit at 4:15 p.m. for four out of five residents.
Cont. on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
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 6
Control Number 29-AS-20220613110952
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: 01/23/2023
NARRATIVE
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The LPA’s substantiated five out of nine allegations, four out of nine were determined as needs further. On 10/21/2022 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. Further investigation is needed prior to issuing final findings. During today’s visit the LPA conducted a physical plant tour at 11:10 a.m., interviewed residents at 11:15 a.m. and 11:17 a.m., interviewed 3rd party at 1:20 p.m., 3:50 p.m and 4:00 p.m. and staff at 5:45 p.m.
Regarding the allegation: Staff did not provide a safe environment for residents in care

The complainant’s concern was that the staff leave knives and a pair of scissors outside which is accessible to the residents. The complainant indicated that knives would be left unlocked in the kitchen drawer and also left on a high shelf in the kitchen cabinet where the dishes were located. Complainant explains that this causes a safety problem due to Resident #1 (R1) being able to reach the dishes in the unlocked cabinet as they are mobile and usually go into the kitchen to help themselves to snacks or food. The LPA observed and confirmed at the time of the visit that sharps were located on the top shelf of the kitchen cabinet and the kitchen drawer containing kitchen knives and sharps was unlocked. Staff indicated that they had been cleaning and were in the middle of moving things around. However, LPA observed that there was no lock for the sharp items in the dish cabinet and the lock being used for the knives drawer was at the back of the drawer in a locked position with no key. Staff located the key in a different area of the facility. Based on observations, this allegation is deemed Substantiated at this time.

Regarding the allegation: Resident sustained falls while in care

The complainant’s concern was that R2 had fallen off their bed a few times. The LPA interviewed staff and residents. Staff confirmed that R2 was being strapped to their wheelchair to prevent them from falling forward when siting up. Staff further confirmed that R3 had obtained sores from falling. Interviews with residents did not reveal a case of falling. However, it is presumed based on staff observations that R2 had fallen out of bed and/or wheelchair and was restrained to prevent them from falling had those falls occurred. However, restraining a resident without an approved exception request for postural supports is not acceptable. Restraints should not be used in replacement of sufficient staffing. Therefore, at this time this allegation is deemed Substantiated at this time.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220613110952
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: To care, supervision, and services that meet their individual needs...This requirement is not met as evidenced by:
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The Administrator agreed to do the following: 1. Submit a Plan of Action, detailing how staff are trained to respond to resident falls (witnessed and unwitnessed). In addition, detail the facility's protocol surrounding fall prevention. Submit to CCL by 1/27/2023.
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Based on the investigation, licensee did not comply with the section cited above, as staff did not provide adequate supervision, resulting in a resident falling, which poses an immediate health and safety risk to residents in care.
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Type B
02/03/2023
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities
...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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The Licensee agreed to do the following:
1. Secure all knives and items that pose risk to residents. POC met.
2.Submit plan of action: how the facility will ensure unsecured items that pose a risk to residents are kept locked and safe moving forward. Submit to CCL by 2/3/2023.
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Based on LPA observation and interviews, the licensee did not ensure a safe environment for residents, which poses a p personal rights risk to residents in care.
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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: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
06/13/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220613110952

FACILITY NAME:BELLA ROSA PLACE, LLC.FACILITY NUMBER:
197604333
ADMINISTRATOR:JOLANTA ROBERTSFACILITY TYPE:
740
ADDRESS:23275 SYLVAN STTELEPHONE:
(818) 625-0517
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
01/23/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Manjit 'Mani' ChadhaTIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained pressure injury while in care
Resident's diapering needs are not being met
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 Manjit ‘Mani’ Chadha over the phone who arrived shortly thereafter and explained the reason for the visit.

On 6/20/2022 Licensing Program Analyst's (LPA's) Elsie Campos and Ashley Smith conducted an unannounced initial complaint visit to the facility. The LPA met with caregiver Feesperanz Pineda explained the reason for the visit. There was two staff and five residents present. The LPA spoke over the phone with the Administrator Solomon Gochin who arrived at the facility shortly thereafter. The LPA’s conducted a plant tour at approximately 9:45 a.m., interviewed staff at 10:02 a.m., 10:20 a.m., and 2:35 p.m., interviewed residents at 11:15 a.m., 11:21 a.m., 11:28 a.m., 11:29 a.m. and 11:55 a.m., conducted a file review at 11:45 a.m., and completed a medication audit at 4:15 p.m. for four out of five residents.
Cont. on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20220613110952
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: 01/23/2023
NARRATIVE
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The LPA’s substantiated five out of nine allegations, four out of nine were determined as needs further. On 10/21/2022 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. Further investigation is needed prior to issuing final findings. During today’s visit the LPA conducted a physical plant tour at 11:10 a.m., interviewed residents at 11:15 a.m. and 11:17 a.m., interviewed 3rd party at 1:20 p.m., 3:50 p.m and 4:00 p.m. and staff at 5:45 p.m.
Regarding the allegation: Resident sustained pressure injury while in care
The complainant’s concern was that Resident #4 (R4) had a bed sore that was not being taken care of properly. Medical records revealed that R4 was on hospice and was noted to have a stage 3 pressure injury on the Sacrum. It was revealed during the course of the investigation, that although R4 had one (1) pressure injury at the time of the initial investigation, R4 developed additional pressure injuries while in care. Medical records revealed that R4 had developed new wounds which included one (1) stage 4 pressure injury on Sacrococcygeal and one (1) stage 3 pressure injury on the L buttock inferior. Additionally, medical records revealed that resident did not have signs of infection. Interview with the hospice nurse confirmed that facility staff were following hospice directions and the resident was being repositioned accordingly. Although the resident did develop wounds, there was insufficient evidence to confirm it was due to a lack of staff care as interviews with the hospice nurse confirmed that the resident’s incontinent care needs were being met and that staff were following all of the hospice nurse’s directions. Based on interviews and medial records reviewed the allegation that resident sustained pressure injuries while in care is deemed Unsubstantiated at this time.
Regarding the allegation: Resident’s diapering needs are not being met
The complainant’s concern was that R4 was not having their diapering needs met. Interviews with staff revealed that all residents are checked multiple times day depending on their incapacity. Interviews with residents revealed that they do their own changing as they do not like to be changed by the caregivers and are capable of doing it themselves. Interview with R4 indicated that they are changed multiple times a day and did not reveal any concerns at the time. Staff interviews confirmed that R4 is changed 3-4 times a day and 1-2 times throughout the night. Based on interviews, the Department does not have sufficient evidence to support the allegation that Resident’s diapering needs are not being met while this allegation may or may not have happened the allegation is deemed Unsubstantiated at this time.

No deficiencies cited regarding the above allegations. Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220613110952
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: 01/23/2023
NARRATIVE
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Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited: (Refer to LIC 9099-D). Exit interview Conducted. Complaint was also discussed with Administrator. Appeal Rights Discussed. A Copy of the Report Issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6