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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604333
Report Date: 10/16/2023
Date Signed: 10/16/2023 04:42:09 PM


Document Has Been Signed on 10/16/2023 04:42 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 N.ASC, 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: 3DATE:
10/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Jolanta Roberts - Licensee RepresentativeTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi, along with WISE and Healthy Aging Long-Term Ombudsman Program (LTCO) Regional Director Ginger Perini conducted an unannounced visit at the above location. At 3:40 p.m., the LPA met with staff and explained the reason for the visit. At 4:03 p.m., the Licensee Representative Jolanta Roberts arrived at the facility.

The purpose of the visit is to ensure there are no health and safety hazards. Between 3:47 p.m. and 4:00 p.m., LPA Peraldi and Ombudsman toured the facility and spoke with three (3) residents. At 4:05 p.m., LPA Peraldi and Ombudsman Perini had several conversations with Jolanta regarding the facility and the change of ownership.

No deficiencies issued. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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