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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604333
Report Date: 04/20/2023
Date Signed: 04/20/2023 04:45:58 PM


Document Has Been Signed on 04/20/2023 04:45 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:BELLA ROSA PLACE, LLC.FACILITY NUMBER:
197604333
ADMINISTRATOR:MANJIT SINGH CHADHAFACILITY TYPE:
740
ADDRESS:23275 SYLVAN STTELEPHONE:
(818) 625-0517
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 6DATE:
04/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Manjit Chadha, AdministratorTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted a case management visit due to the deficiencies observed during a visit to this facility. The case management visit was conducted with Manjit Chadha, Administrator. The reason for this visit was explained. A tour of the physical plant was conducted and no obvious deficiencies were observed. The following deficiencies were observed:
  • Per file review conducted at 11:54am for Valiant R. Po, it was observed that he has an incomplete file. Many required forms were blank, including Personnel Report, no Physician's Report with the results of a TB test, an expired first aid card that was issued on 4/20/21 and good for 2 years and a blank LIC 9182 Criminal Background Clearance Transfer Request. LPA Yee verified with Department staff to confirm if staff was associated to the facility. As of today's visit, Valiant Po is not associated to this facility

  • Food supply was reviewed and it was observed that the facility did not have sufficient non-perishable foods to last 7 days for 6 residents, maintained on the premises. Per staff, a list of food to be purchased was given to the Administrator.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. CIVIL PENALTIES WERE ASSESSED.
Exit interview was conducted, Appeals Rights Discussed and a copy of the report was provided
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
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 04/20/2023 04:45 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BELLA ROSA PLACE, LLC.
FACILITY NUMBER: 197604333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2023
Section Cited

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General Food Services Requirement:(b)The following food service requirements shall apply: Supplies of nonperishable foods or a minimum of one week and perishable foods for a minimum of
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The Licensee will purchase additional foods, such as pasta sauces, variety of canned proteins, soups, additional cereal, oatmeal and snack foods to allow for preparation of 3 balanced meals per day for 6 residents.
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 two days shall be maintained on the premises. This requirement was not met as evidenced by: canned goods observed were not in quantities to last the required 7 days and there were no sauces for the pasta and only 2 packages of cereal. The quantities of food would not allow for preparation of balanced meals
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Licensee will submit a copy of the receipt to Licensing by 4/21/23.
Type B
04/28/2023
Section Cited

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Personnel Requirements General:All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
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The Licensee will ensure that all staff provide evidence of current first aid training at the time of hire. Licensee will ensure that Valiant Po is not left alone with a resident until first aid training is completed
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Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. Staff, Valiant R. Po does not have a current First Aid card
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Fax over evidence of completion of first aid training by 4/28/23
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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2023 04:45 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BELLA ROSA PLACE, LLC.
FACILITY NUMBER: 197604333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2023
Section Cited

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Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met as evidenced during file review
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The Licensee will read Title 22 Section 87412 and will ensure that all the documents required in all the staff's files are maintained in the staff files. The Licensee will submit a signed stafement that the section was
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Staff file for Valiant Po contained blank forms
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read and all the required forms have been obtained and maintained in all the staff files by 5/05/23

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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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2023 04:45 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BELLA ROSA PLACE, LLC.
FACILITY NUMBER: 197604333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2023
Section Cited

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Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a
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Licensee will ensure that all staff have obtained a criminal record clearance or have requested a criminal record transfer prior to being present at the facility. Provide evidence that Valiant Po has
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icensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or Staff, Valiant Po was not associated to the facility as of today's visit. DOH 4/10/23
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been associated to the facility by 4/21/23.

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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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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