197604333-2-24-2023-29-AS-AASO-CPCRZR-20230224122822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604333
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:31:46 PM

Document Has Been Signed on 02/24/2023 12:31 PM - It Cannot Be Edited

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:	MANJIT SINGH CHADHA		FACILITY TYPE:	740
ADDRESS:	23275 SYLVAN ST		TELEPHONE:	(818) 625-0517
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 4	DATE:	02/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Manny Chadha		TIME COMPLETED:	12:40 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 Analyst (LPA) Angel Ascencio conducted an unannounced required annual visit to the above facility. LPA Ascencio met with the Staff Evangeline (Eva) Zinampan and explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures. At 10:05 a.m., LPA, along with Staff Eva toured the physical plant areas inside and outside to ensure there are no health and safety hazards. Administrator Manjit (Manny) Singh Chadha arrived at the facility at 12:05 p.m BEDROOMS: Resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds. The home has a total of four (4) bedrooms for resident use - two (2) are private bed rooms, two (2) is a shared bedrooms, and 1 is a live-in staff only room. RESTROOMS: There are three (3) total bathrooms at the home; one (1) is a common restroom, 1 is a shared bathroom, 1 is in the garage for staff only. The resident bathrooms consist on a sink, a toilet and a shower with non-skid materials. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/24/2023 12:31 PM - It Cannot Be Edited

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: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the water temperature in the kitchen was 133.3 degree F and the common restroom was 134.3 degree F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2023
	Plan of Correction
1 2 3 4	Administrator will lower the water temperature to the appropriate range. Administrator will submit a 3 times a day, for 3 days temperature log and submit to CCL by 02/27/2023.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as Clorox Disinfectant wipes were on the kitchen counter which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2023
	Plan of Correction
1 2 3 4	Staff placed the item in a locked location. Administrator will contract an outside agency to conduct training on 87309 (a). Administrator will submit documentation and attendees to CCL by 03/03/2023.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/24/2023 12:31 PM - It Cannot Be Edited

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: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as NovoLog Flex Pen Prefilled Syringes, Centrum Multivitamin, Vitamin B-1 and Vitamin D3 were not safe and not locked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2023
	Plan of Correction
1 2 3 4	During visit, staff placed in an unaccesible location. Administrator will contract an outside agency to conduct training on 87465 (h)(2). Administrator will submit documentation and attendees to CCL by 03/03/2023.

Type A

Section Cited

CCR

87555(b)(8)

87555(b)(8) General Food Service Requirement: The following food service requirement shall apply: All food shall be of good quality... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in various cabbages/lettuces were oberved to be in poor quality which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2023
	Plan of Correction
1 2 3 4	Administrator agreed to do the following: 1. Audit food; throw out food that is of poor quality. Inform CCL no later that 02/27/2023.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 02/24/2023

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The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be
serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and
operated normally at the time of visit. The medication cabinet was observed to be locked and contained at
least 30 days of worth of medication. The garage is accessible within the home and was noted to be locked. The garage contains the laundry room and laundry supply. The outdoor patio has a covered outdoor area equipped with furniture for resident use. The There are no bodies of water noted.

KITCHEN: Kitchen knives are stored in a cabinet in the kitchen. The supply of dishes,
utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees
Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable
food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation
area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had
tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked garage. No flies or
other vermin were observed

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff member regarding the
facility’s infection control practices at 11:45 a.m. There is 1 entry into the facility. The LPA noted that the
facility is allowing visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of
Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The
facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation
room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of
COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

At 10:07 a.m., NovoLog FlexPen Prefilled Syringes was observed in a kitchen fridge, accessible to residents in care. At 10:09 a.m. Clorox Disinfectant wipes were observed in the kitchen counter accessible to residents in care. At 10:10 a.m. Centrum Multivitamins, Vitamin B-1 100mg, and Vitamin D3 125 mcg. were observed unlocked and accessible to resident in care. At 10:16 a.m., Cabbages/Lettuces were observed in poor quality in a fridge located in the backyard. At 10:18 a.m. and 10:19 a.m., hot water temperature was tested in the kitchen at 133.3 degree F and common restroom at 134.3 degree F.

4 deficiencies were issued, 2 of which are repeat violation were issued for a total of $500.00.
Exit interview conducted, and a copy of the report, appeal rights and civil penalties were issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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