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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197604333
Report Date:
03/29/2022
Date Signed:
03/29/2022 01:31:39 PM
Document Has Been Signed on
03/29/2022 01:31 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 ROBERTS
FACILITY TYPE:
740
ADDRESS:
23275 SYLVAN ST
TELEPHONE:
(818) 625-0517
CITY:
WOODLAND HILLS
STATE:
CA
ZIP CODE:
91367
CAPACITY:
6
CENSUS:
DATE:
03/29/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Feesperanz Pineda
TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Staff Feesperanz Pineda at 9:30 a.m. and explained the reason for the visit.
The LPA toured the physical plant areas inside and outside, with Feesperanz Pineda at 9:30 a.m. to ensure there are no health and safety hazards.
BEDROOMS:
The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS:
Resident restrooms are clean, sanitary, and in operating condition with grab bars. The LPA observed the private resident bathroom without a non-skid mat, a broken cabinet knob and a broken toilet paper holder. The LPA observed sufficient amounts of soap and paper products at the time of the visit. The LPA advised the Administrators to ensure that bathrooms displayed appropriate hand-washing signs. Hot water temperatures measured between 138.6 and 142.0 degrees Fahrenheit between 9:49 a.m. and 9:57 a.m. in the common and private bathroom(s).
Continued on LIC 809-C
SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2022
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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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
VISIT DATE:
03/29/2022
NARRATIVE
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KITCHEN:
Kitchen appliances were in operable condition. At 9:44 a.m., during the tour of the kitchen, the LPA observed expired cooking spices consisting of turmeric powder expiration 1/6/2022, cloves powder expiration 1/24/22 and curry powder expiration 1/24/22. The LPA observed that the facility’s supply of perishable fresh vegetables was found to be insufficient for six (6) residents and one (1) staff. The supply of fresh vegetables was observed today to be (2) two bags of broccoli, (3) three bags of shredded lettuce, (1) one sack of potatoes and (1) one onion. The tomatoes were observed to be expired with mold growth. The LPA advised staff to throw them out immediately upon discovery. At 9:41 a.m. the LPA observed the freezer located outside containing additional food to be dirty as it was observed something had spilled and not cleaned up. The LPA advised staff to ensure that was cleaned immediately. The emergency non-perishable food for (6) six residents, and (1) one staff was found to be sufficient. The LPA observed (3) three fire extinguishers in the kitchen area without date of service or proof of purchase. All knives were observed to be properly stored and locked at time of visit however, cleaning supplies located under the kitchen sink were observed to be unlocked and accessible to residents. Hot water measured 142.6 degrees Fahrenheit at 9:50 a.m.
COMMON SPACES
: In the common areas, walls and flooring were checked for cleanliness and good condition. At 9:31AM, the garage and laundry was observed to be unlocked, and there were accessible laundry supplies and chemicals. Staff was unable to locate a key to secure the area. The LPA advised the Administrator that this needed to be corrected immediately.
At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed appropriate handwashing and cough etiquette postings in the hallway. However, the LPA did not observe the appropriate postings at facility entrance with updates to visitor policy notifying visitors of policies and procedures necessary to protect residents from infection during pandemic. At 10:00 a.m., two (2) fire extinguishers were observed in the living room without date of service or proof of purchase. Smoke detectors and carbon monoxide detectors are hardwired and interconnected and tested at 10:03 a.m.
BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted.
Continued on LIC-809-C
SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2022
LIC809
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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
VISIT DATE:
03/29/2022
NARRATIVE
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INFECTION CONTROL:
During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.
The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.
Exit interview conducted. A copy of the report and appeal rights were provided via Email.
SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2022
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
03/29/2022 01:31 PM
- It Cannot Be Edited
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:
03/29/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above, as the hot water registered above 120 degrees farenheit, which poses an immediate health and safety risk to persons in care.
POC Due Date:
04/04/2022
Plan of Correction
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2
3
4
The adminsitrator agreed to do the following:
1. Adjust the water heater no later than today 3/29/22 and advise CCL.
2. Complete a 5 day log of hot water temperature. Submit to CCL no later than 4/4/22.
Type A
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above as in a resident bathroom did not have the required non-skid mat which poses an immediate health and safety risk to persons in care.
POC Due Date:
04/01/2022
Plan of Correction
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The adminsitrator agreed to do the following:
1. Ensure that all bathrooms have the required non-skid mats and submit proof to CCL no later than 4/1/22.
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
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2022
LIC809
(FAS) - (06/04)
Page:
4
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Document Has Been Signed on
03/29/2022 01:31 PM
- It Cannot Be Edited
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:
03/29/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate 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:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above as the fire extinguishers did not have verifiable date of last service or proof of purchase, which poses a potential health and safety risk to persons in care.
POC Due Date:
04/08/2022
Plan of Correction
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The administrator agreed to do the following:
Purchase or service fire extinguishers and submit proof to CCL no later than POC date.
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as fresh food items and non-perishable food items were noted to be past expiration which poses an immediate health and safety risk to residents in care.
POC Due Date:
03/30/2022
Plan of Correction
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Administrator agreed to discard expired food items and mark food items with labels and expiration dates. At the time of the inspection, the LPA observed staff discard expired food items.
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
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2022
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
03/29/2022 01:31 PM
- It Cannot Be Edited
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:
03/29/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
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.
POC Due Date:
03/29/2022
Plan of Correction
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4
The Administrator agreed to do the following:
1. Secure the items. Inform the Department when this takes place, but no later than 3/29/22. This is a repeat violation and civil penalties will be assessed.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2022
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
03/29/2022 01:31 PM
- It Cannot Be Edited
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:
03/29/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the LPA observed a cabinet knob and toilet paper holder in disrepair in the private resident bathroom which poses/posed a potential personal rights risk to persons in care.
POC Due Date:
04/04/2022
Plan of Correction
1
2
3
4
The administrator agreed to the following:
Make the repairs and submit proof to CCL no later than the POC date.
Type B
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the LPA observed the freezer containing food items to be dirty with spilled liquids which poses potential health and safety risk to persons in care.
POC Due Date:
03/29/2022
Plan of Correction
1
2
3
4
The administrator agreed to the following:
Have the freezer cleaned and submit proof to CCL no later than 3/29/22.
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
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2022
LIC809
(FAS) - (06/04)
Page:
7
of
7