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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600145
Report Date: 11/21/2023
Date Signed: 11/22/2023 10:30:45 AM

Document Has Been Signed on 11/22/2023 10:30 AM - 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BELL GARDENS MANORFACILITY NUMBER:
198600145
ADMINISTRATOR:MARIA ZUNIGAFACILITY TYPE:
735
ADDRESS:8424 S EASTERNTELEPHONE:
(562) 927-1389
CITY:BELL GARDENSSTATE: CAZIP CODE:
90201
CAPACITY: 141CENSUS: 71DATE:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maria ZunigaTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Maria Zuniga and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA toured the facility along with Administrator Maria Zuniga today 11/21/2023 at 1:40 PM and the following was observed:
Facility contains 56 Client Bedrooms dining room, and TV room.
LPA inspected Rooms 113, 117, 123, 128, 129, 137 and 138 and the water temperature measured between 105 F- 120F.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records-Training, Client Rights- Information, Client records- Incident Reports, Food Service, Health related services, Incidental Medical Services, and Disaster Preparedness.
Interviews were conducted with 3 staff and 5 clients. 7 client files were reviewed and 7 staff files were reviewed. All staff were cleared and associated.
Medication was administered per physician's directions.
Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
There is an adequate number of direct care staff to support each resident's physical, social, emotional safety and health care needs as identified in his/her current appraisal.
Facility has a sufficient supply of PPE.
First Aid for staff was not current for 7 staff files reviewed.
Deficiency cited on the 809 D. Exit interview conducted and copy provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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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Document Has Been Signed on 11/22/2023 10:30 AM - It Cannot Be Edited


Created By: Glenn Trueman On 11/21/2023 at 03:04 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELL GARDENS MANOR
FACILITY NUMBER: 198600145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
Based on record review , the licensee did not comply with the section cited above in 7 out of 7 persons not having current First Aid which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator to submit to Licensing current First Aid by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
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