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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608788
Report Date: 01/06/2023
Date Signed: 01/31/2023 03:26:53 PM

Document Has Been Signed on 01/31/2023 03:26 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MERIDIAN AT BELLA MARFACILITY NUMBER:
197608788
ADMINISTRATOR:SHAWN C. MOONEYFACILITY TYPE:
740
ADDRESS:825 OCEAN AVETELEPHONE:
(310) 393-5258
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY: 36CENSUS: 11DATE:
01/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Anita CsukardiTIME COMPLETED:
04:22 PM
NARRATIVE
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On 1/06/23 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Case Management Visit to this facility with LPA and Program Director, Anita Csukardi.
Deficiencies were observed during today's visit. Title 22 Regulations are being cited, please see LIC809D.
An exit interview was conducted and plans of corrections were developed.
A copy of this report and appeals rights were provided to Anita Csukardi.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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 3
Document Has Been Signed on 01/31/2023 03:26 PM - It Cannot Be Edited


Created By: Mario Leon On 01/06/2023 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MERIDIAN AT BELLA MAR
FACILITY NUMBER: 197608788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2023
Section Cited

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Transfer of resident upon..The department shall approve or disapprove the closure plan,..requirements:..residents. Until the department has approved a licensee’s closure plan, the facility shall not issue a notice of transfer or require any resident to transfer
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This requirement was not met as evidenced by: Based on record reviews the licensee failed to obtain the Departments approval of the Closure Plan prior to requiring residents to transfer which poses a potential health and safety risk to residents in Care.
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Type B
01/09/2023
Section Cited

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Eviction Procedures. The licensee shall set forth in the notice to quit..reasons. Resources available..needs. A statement informing residents of their right to file a complaint..office. The following exact statement as specified in … 1569.683(a)(4):"In order to..complaint. You..hearing"
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This requirement was not met as evidenced by: Based on..reviews..licensee failed..information as req'd by Title 22 Regulation 87224(d)(1)(B-D) in the 60 Day Notices issued to residents on 01/02/23, which poses a potential health and safety risk to resident 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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/31/2023 03:26 PM - It Cannot Be Edited


Created By: Mario Leon On 01/06/2023 at 03:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MERIDIAN AT BELLA MAR
FACILITY NUMBER: 197608788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2023
Section Cited

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Domain Focused
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.
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This requirement was not met as evidenced by: Based on LPA Mario Leon's observation, both public restroom and resident's restroom in room 11 were both "out of order".
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023


LIC809 (FAS) - (06/04)
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