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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604333
Report Date: 07/01/2022
Date Signed: 07/01/2022 05:14:25 PM


Document Has Been Signed on 07/01/2022 05:14 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:
07/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Solomon Gochin-AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos arrived at the facility today for a Plan of Correction (POC) visit. The purpose of the visit is to confirm corrected citations issued from the complaint control number 29-AS-20220613110952 and case management visit conducted on 6/20/2022. The LPAs spoke with the Administrator and informed her of the reason for the visit.

87608(a)(3) Postural Support. On 6/20/2022, the licensee was cited for not having an order on file for a postural support. The licensee was supposed to submit the order for the postural support for Resident #1 (R1) by 6/27/2022. At this time, the licensee does not have the order for the postural support, nor did the licensee reach out to request an extension. At this time, the Plan of Correction is not met; civil penalties will be assessed.

87555(a)(8) General Food Service Requirements. On 6/20/2022, the licensee was cited as the LPAs observed expired food. The Licensee was instructed to buy more food and send photos and/or receipts by 6/21/2022. During today’s visit, the LPAs audited the food. Whereas the facility purchased additional food, the LPAs observed additional food in poor quality and expired. At this time, the facility will be re-cited for failure to have food in poor quality.

87465(a)(4) Incidental Medical and Dental Care. On 6/20/2022, the licensee was cited due to observed medication errors in the medication audit. The Licensee was instructed schedule a medications training for all staff and inform the Department of the scheduled training by 6/23/2022. During today's visit it was noted that training was scheduled and completed on 6/27/2022. At this time, the Plan of Correction is met.

Continued LIC-809-C
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
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 4


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: 07/01/2022
NARRATIVE
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87202(a) Fire Clearance. On 6/20/2022, it was observed that R1 was deemed bedridden, yet the facility did not have a bedridden fire clearance. The Licensee was instructed to submit an updated LIC200 and facility sketch by 6/20/2022. At this time, the licensee did not submit the documents, nor did the licensee reach out to request an extension. At this time, the Plan of Correction is not met; civil penalties will be assessed.

87705(f)(2) Care of Persons with Dementia. On 6/20/2022, over-the-counter medications and cleaning supplies were accessible. The Licensee was instructed to secure the items and inform the Department when it was completed, yet no later than 6/21/2022. During today's visit the LPA's did not observe any over the counter medications or cleaning supplies accessible. Plan of correction met.

During today's visit the LPA's observed staff not wearing face masks upon entry. At 3:43 p.m., the LPAs observed prescribed medication accessible in the refrigerator.

The Administrator was instcuted to inform the LPAs of any noted Plan of Corrections either at EMAIL: Elsie.Campos@dss.ca.gov or phone number 747-230-3909.


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.


An exit interview was conducted. A copy of this report, LIC 421FC, and Appeal Rights were discussed and provided to the Administrator, whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/01/2022 05:14 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: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/05/2022
Section Cited

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87555(b)(8) General Food Service Requirements. The following food service requirements shall apply: All food shall be of good quality...
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 multiple food items were found to be expired which poses an immediate personal rights risk to residents in care.
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Type A
07/05/2022
Section Cited

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87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by
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This requirement was not met as evidenced by:
Based on observations and interview, the licensee did not comply with the section cited above, as staff were not wearing face masks in the facility, which poses an immediate personal rights 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: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/01/2022 05:14 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: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2022
Section Cited

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87465 Incidental Medical and Dental Care Services (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
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Based on LPA's observation, the licensee did not comply with the section cited above as resident medications were accessible to residents which posed an immediate health risk to persons 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: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4