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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604333
Report Date: 02/02/2024
Date Signed: 02/02/2024 06:35:16 PM


Document Has Been Signed on 02/02/2024 06:35 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:
02/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Pogos Tofalyan, ApplicantTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced case management visit to this location along with Long Term Care Ombudsman Ginger Perini. At 12:40 p.m., the LPA and Ombudsman met with staff. At 2:15 p.m., the Landlord of the property, Jolanta Roberts arrived at the facility. At 5:10 p.m., the Applicant, Pogos Tofalyan arrived at the facility.

On 01/25/2024, LPAs Peraldi and Arroyo delivered denial letters that was sent via certified mail on January 23, 2024. Additionally on 01/25/2024, Pogos Tofalyan was served a second Notice of Operation in Violation of Law (NOVL). An initial NOVL was served to Pogos Tofalyan on December 15, 2023. On 01/25/2024, LPAs provided a copy of the Department’s application denial letter for this property. Per the NOVL, Mr. Tofalyan must relocate all individuals requiring care and supervision by February 14, 2024. It was also explained to Mr. Tofalyan that per Health and Safety Code 1569.16(b), re-submitting an application will not correct the citation, as an applicant does not have the right to re-apply for licensure for one year after the Department’s application denial.

During today’s visit, the LPA and Ombudsman observed four (4) individuals residing at the facility that require care and supervision. Upon arrival, the LPA observed a newly admitted resident. Based on assessment, Emergency Medical Services (EMS) personnel were called, and three (3) out of four (4) residents were transported to the hospital for further evaluation. One (1) out of four (4) residents was transported back to a licensed facility. During the time of the visit, the LPA spoke with resident’s family members and explained the hospitalization's.

Exit interview conducted with applicant, Pogos Tofalyan. A copy of the report was provided to the applicant.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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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