197604333-8-30-2022-29-AS-JAPL-CJ8PQJ-20220913113110

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604333
Report Date: 08/30/2022
Date Signed: 08/30/2022 03:36:13 PM

Substantiated

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
08/29/2022 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20220829104449

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:	08/30/2022
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Emily Mosquito		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Excluded individual is allowed in the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial 10-day visit. The LPA spoke with staff Emily Mosquito and explained the reason for the visit. Administrator Solomon Gochin was unavailable; yet was notified of the reason for the visit. During today’s visit, the LPA interviewed staff at 1:30 p.m., 1:50 p.m. and 2:06 p.m., and interviewed residents at 1:40 p.m., 1:45 p.m., 1:55 p.m., and 1:57 p.m.

Regarding the allegation, it was alleged that Gbolabo Folayan has presented themselves as the primary contact of this facility and is known to collateral agencies as the administrator of this facility. However, per review of the Caregiver Background Check System, Mr. Folayan is excluded. Records indicate that Mr. Folayan was previously the Administrator for this location. A file review confirmed that on 1/27/2020, LPA Michael Cava conducted a case management visit with the licensee and informed them of the status regarding Gbolabo Folayan, noting pursuant to the Decision and Order issued on 10/18/2019, that Mr. Folayan can no longer be present at the facility or serve duties as an administrator at any facility licensed by the Department. The order went into effect 01/19/2020.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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-20220829104449

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: 08/30/2022

NARRATIVE

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Interviews noted that Solomon Gochin is currently the administrator for this facility. Evidence obtained from credible witnesses revealed that Mr. Folayan was last observed at this facility on 3/23/2022 and 7/7/2022, and that Mr. Folayan has been in the facility ‘frequently’. Additional evidence obtained claimed that staff identified Mr. Folayan as 'the boss' and the individual they would speak to regarding concerns or issues. Information obtained from today's interviews confirmed claims that Mr. Folayan had been observed inside the facility and has worked in the capacity of communicating with and placing residents at this location.

The Department obtained a Decision and Order effective 01/19/2020 excluding Gbolabo Folayan from being a licensee, owning beneficial ownership interest of 10 percent or more in a licensed facility, or being an administrator, officer, director, member, or manager of a licensee or entity controlling a licensee and further, from employment in, presence in, and from contact with clients of, of any facility licensed by the Department, for the remainder of their life.

Based on the information obtained and the interviews conducted, there is sufficient evidence to support the claim that Gbolabo Folayan, whom is excluded, has been present at this facility since the Decision and Order went in effect 01/19/2020. The allegation is deemed Substantiated at this time.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited: (Refer to LIC 9099-D). Civil penalties assessed. Exit interview Conducted. Complaint was also discussed with licensee Jolanta Roberts. Staff were authorized to sign the report. Appeal Rights Discussed. A Copy of the Report Issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220829104449

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/01/2022 Section Cited CCR 1569.58(a)(2)	1 2 3 4 5 6 7	§1569.58(a)(2) The department may prohibit any person from being a licensee … an administrator … and ... prohibit any licensee from employing … or allowing contact with clients of a licensed facility … who has done … the following: (2) Engaged in conduct that is inimical to the health ... welfare, or safety ...	1 2 3 4 5 6 7	The Administrator has agreed to do the following: Review Health and Safety Code 1569.58 and Regulation 87355 with all staff. Submit Statement of Understanding and sign-in sheet, acknowledging review, by 9/1/2022
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as an excluded individual has been seen in the facility and has had regular contact with clients, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Zero tolerance violation, civil penalties assessed in the amount of $500.
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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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC9099 (FAS) - (06/04)

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