197604333-1-20-2022-29-AS-JAPL-CB2S9L-20220126124051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604333
Report Date: 01/20/2022
Date Signed: 01/20/2022 12:11:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220110131832

FACILITY NAME:	BELLA ROSA PLACE, LLC.		FACILITY NUMBER:	197604333
ADMINISTRATOR:	JOLANTA ROBERTS		FACILITY TYPE:	740
ADDRESS:	23275 SYLVAN ST		TELEPHONE:	(818) 625-0517
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	01/20/2022
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Feesperanz Pineda		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility failed to provide residents with hygiene supplies.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced initial complaint visit to the facility today. The LPA met with caregiver Feesperanz Pineda explained the reason for the visit. There was two staff and five residents present. The LPA spoke with the Administrator Jolanta Roberts who was unable to come to the facility.

Today, the LPA interviewed staff at 9:00 a.m. and 9:15 a.m., conducted a tour, and interviewed a resident at 9:20 a.m.

Cont. 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220110131832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/20/2022

NARRATIVE

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Regarding the allegation it was alleged that facility failed to provide residents with hygiene supplies. Staff interviews revealed that the facility has always had paper supplies and supplies are replenished at the end of the month. Staff negated claims that the facility was out of toilet paper at any point in time and communicated that they were responsible for ensuring that all bathrooms were stocked with toilet paper. If supplies run low, they can be ordered as needed. The staff are responsible for reporting to the administrator when supplies are needed. Staff mentioned that one resident room had an attached bathroom, and that the bathroom is always stocked with an adequate amount of toilet paper. Staff claim that residents are provided with toilet paper when requested, and that the surplus toilet paper is kept in storage. Staff checks all bathrooms every morning in addition to their daily cleaning routine. Staff claim that additional surplus of toilet paper is not kept in resident bathrooms to mitigate toilet clogging when residents overuse of toilet paper.

During the tour the LPA observed toilet paper in the supply closet and in all bathrooms.

Based on the investigation there is insufficient evidence to support the claim that the facility does not provide residents with hygiene supplies. This allegation is deemed unsubstantiated at this time.

No deficiencies cited regarding the complaint. Case management visit issued to address deficiencies cited during today's visit which are unrelated to the complaint.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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