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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604333
Report Date: 06/20/2022
Date Signed: 06/20/2022 07:05:46 PM

Document Has Been Signed on 06/20/2022 07:05 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:JOLANTA ROBERTSFACILITY TYPE:
740
ADDRESS:23275 SYLVAN STTELEPHONE:
(818) 625-0517
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 5DATE:
06/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Solomon GochinTIME COMPLETED:
07:10 PM
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Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20220613110952.

During today’s investigation, the LPAs conducted a file review and confirmed that Resident #1 (R1) is deemed bedridden. The physician’s report, dated 1/21/2021, noted that R1 was bedridden. Further review of R1’s physician’s report indicated that R1 required assistance with activities of daily living, which included assistance with dressing, grooming, feeding, toileting, and transferring. R1 is on hospice. The LPAs reviewed the facility’s fire clearance dated 9/6/2006, which indicated that the retention of a bedridden client was not to exceed two weeks.

During today's physical plant tour, the LPA observed accessible medications in Resident #2 (R2)'s room at 11:22 a.m., and accessible cleaning supplies in an unlocked cabinet at 9:51 a.m. Also the garage was unlocked, which is where the laundry detergent is held. In addition, during the file review, the facility did not have completed staff files for two out of three staff on record (Staff #1, Staff #2).

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalties assessed for a zero-tolerance violation. Exit interview conducted. A copy of the report, and appeal rights, were filed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/20/2022 07:05 PM - It Cannot Be Edited


Created By: Ashley Smith On 06/20/2022 at 05:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2022
Section Cited
CCR
87202

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87202(a) Fire Clearance. (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit Application LIC200 and facility sketch to CCL office to request a bedridden fire clearance for R1.
Administrator stated if bedridden fire clearance is not approved, the resident will be relocated.
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above in one out of five residents (R1) which poses an immediate health and safety risk to residents in care.
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Immediate civil penalty in the amount of $500 will be assessed.
Type A
06/21/2022
Section Cited
CCR87705(f)(2)

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87705(f)(2)Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins... cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Secure the items. Inform the Department when this takes place, but no later than 6/21/22.

This is a repeat violation and civil penalties will be assessed.
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Based on observation, the licensee did not comply with the section cited above, as over the counter medications and cleaning supplies were accessible, which poses an immediate health and safety risk to residents 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/20/2022 07:05 PM - It Cannot Be Edited


Created By: Ashley Smith On 06/20/2022 at 05:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2022
Section Cited
CCR
87412(a)

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87412(a) Personnel Records.The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Update the staff files; inform CCL when this has taken place, but no later than 7/5/222.
2. Submit a Plan of Action, detailing how the facility will maintain voluntary compliance. Submit no later than 7/5/2022.
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Based on record review, the licensee did not comply with the section cited above in two out of three staff files, which poses a potential health and safety risk to residents 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022


LIC809 (FAS) - (06/04)
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