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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604333
Report Date: 01/11/2024
Date Signed: 01/11/2024 01:09:34 PM


Document Has Been Signed on 01/11/2024 01:09 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: 4DATE:
01/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Evangeline Zinampan, staffTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced visit at the above location. At 12:50 p.m., the LPA met with staff and explained the reason for the visit. At 12:58 p.m., the LPA spoke with the applicant, Pogos Tofalyan over the telephone. The applicant was not available during the time of the visit and authorized staff, Evangeline Zinampan to sign the report.

The purpose of the visit is to ensure there are no health and safety hazards. At 12:52 p.m., the LPAs along with staff toured the facility. The LPA observed four (4) residents at this location.

The LPA spoke with Applicant, Pogos Tofalyan with concerns at the facility that include:
- The amount of perishable and non-perishable food available to the residents.
- Staff schedules including coverage for caregivers and administrative staff.
- Complete resident files.
The Applicant, Pogos Tofalyan explained that the above items will be worked on today.

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: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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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