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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604333
Report Date: 01/20/2022
Date Signed: 01/20/2022 12:12:54 PM

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:
01/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Feesperanz PinedaTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) 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-20220110131832.

During today’s investigation, at 9:00 a.m. the LPA observed unsecured laundry detergent and cleaning supplies in the laundry room through the garage. At 9:06 a.m., lighters were observed accessible in the kitchen drawer. At 9:07 a.m. the cabinet under the kitchen sink containing cleaning supplies cabinet was unlocked. At 9:08 a.m., the LPA observed over-the-counter creams and ointments observed in an unlocked hallway closet.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties assessed for a repeat violation. The Administrator authorized staff to sign the report.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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 2
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: 01/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2022
Section Cited

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87705(f)(1) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as a lighter and and a hammer were accessible, which poses an immediate health and safety risk to residents in care.
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Type A
01/20/2022
Section Cited

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87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins .... toxic substances such.. cleaning supplies and disinfectants. This requirement is not met as evidenced by:
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2022
LIC809 (FAS) - (06/04)
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