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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604333
Report Date: 12/15/2023
Date Signed: 12/15/2023 03:23:07 PM


Document Has Been Signed on 12/15/2023 03:23 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 CHADHAFACILITY TYPE:
740
ADDRESS:23275 SYLVAN STTELEPHONE:
(818) 625-0517
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
12/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Evangeline ZinampanTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Martha Arroyo and Emily Peraldi conducted an unannounced visit to this location for the purpose of delivering Notice of Operation in Violation of Law (NOVL) issued on 12/15/2023. Upon arrival, LPAs met with staff Evangeline Zinampan.

At 1:18 p.m., LPAs gained entry onto the property and observed four (4) residents and one (1) staff. During today’s visit, the LPAs conducted a physical plant tour and observed sufficient amount of perishable and non-perishable food. At 2:53 p.m., LPA Peraldi spoke with the Applicant, Pogos Tofalyan. regarding the reason for the NOVL. The LPA informed the Applicant that at this time, he is operating unlicensed, and a completed application needs to be submitted in order to be in compliance of section 1569.10 and/or 1569.44 of the Health & Safety Code.

A Notice of Operation in Violation of Law (NOVL) was issued. The Applicant was advised that a retroactive civil penalty of $100 per day per tenant shall be assessed on the 16th day from the original date of the notice of Operation in Violation of the Law (December 15, 2023) for the operation of an unlicensed facility. If the operator has not ceased operation or submitted a completed application for licensure within 15 calendar days of the issuance of this notice. On the 16th day from the notice, if the unlicensed operation continues to operate, a $200 per tenant per day will be assessed until a completed application is submitted or the operation ceases.

The Applicant may submit a complete application at the Woodland Hills Adult and Senior Care Regional Office located 21731 Ventura Blvd STE 250, Woodland Hills, 91364. The Applicant may go to www.ccld.ca.gov for orientation information. The LPAs reminded the Applicant to not take in additional residents.
Citation was issued per Health and Safety Code. See LIC 9099-D included with this report.
Exit interview conducted. Appeal rights and a copy of the report was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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 12/15/2023 03:23 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: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2023
Section Cited
CCR
1569.10

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HSC: 1569.10. RCFE; license or permit; necessity: No person… corporation... shall operate…conduct, or maintain a residential facility for the elderly in this state without a current valid license or current valid ...This requirement was not met as evidenced by:
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Applicant was informed to either relocate residents (in need of care and supervision) to a licensed facility or submit a complete application within 15 calendar days of this date. LPAs advised Applicant that they have 15 days to complete the plan of correction. If uncorrected, civil penalties will be assessed.
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Based on interviews and record review, the Applicant did not comply with the section cited above as the Applicant did not submit a complete application which poses an immediate health and safety risk to tenants 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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