198600216-5-19-2023-11-AS-FSHY-CRYPT5-20230519113521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600216
Report Date: 05/19/2023
Date Signed: 05/19/2023 11:35:28 AM

Document Has Been Signed on 05/19/2023 11:35 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	STRATA BELLA HOME		FACILITY NUMBER:	198600216
ADMINISTRATOR:	BELLOSILLO, JOHNETTE		FACILITY TYPE:	735
ADDRESS:	23217 HUBER AVENUE		TELEPHONE:	(310) 534-8453
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 4		CENSUS:	DATE:	05/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Johnett Bellosillo		TIME COMPLETED:	11:35 AM

NARRATIVE

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On 5/19/23 at 8:52 am, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, Rizalinda Cay-an, Caregiver called the Administrator Johnette Bellosillo. LPA explained the purpose of this visit to the licensee and was granted entry. Census is 4.

The facility has an approve mitigation plan report.

LPA Shirley and Staff Sally, (Rizalinda Cayan-an), toured the inside and outside grounds of the facility.

The facility is licensed to serve four (4) non-ambulatory clients ages 18-59, approved for non-ambulatory with a hospice waiver of two clients. The facility is vendored by the Harbor Regional Center.

During the tour, LPA observed the facility’s infection control practices. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility has one central entry and a designated visitation area. LPA observed required postings throughout the facility.

LPA observed the facility consists of living room, office area, TV room, kitchen, dining area, medication closet, two (2) bathrooms, four (4) client bedrooms, washer and dryer in garage, two (2) garages (one used for storage), and backyard. Centrally stored medications are inaccessible to clients. Disinfects, cleaning solutions, detergent, toxins are inaccessible to clients. There is at least a one-week supply of nonperishable and two-day supply of perishable foods. The facility is maintained at a comfortable temperature. Hot water temperatures in both bathrooms measures at 112.2 degrees Fahrenheit.

Con'd on 809C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STRATA BELLA HOME	FACILITY NUMBER: 198600216
	VISIT DATE: 05/19/2023

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There are working lights in each room to ensure safety and comfort for all clients in the facility. The clients have clean linen which includes blankets/bedspreads, top and bottom sheets, pillowcases, and mattress pads. First aid kit had the required items. The facility has a written emergency disaster plan located in hallway. This facility has two operable carbon monoxide detectors located in the living room and a client's bedroom, operable smoke detectors in all the bedrooms and hallway. LPA observed one (1) fire extinguisher located in the kitchen was serviced on 4/23.

Deficiencies were cited during this visit. Exit interview conducted and a copy of this report was provided to and signed by Caregiver Rizalinda Cay-an to give to Licensee Johnett Bellosillo.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/19/2023 11:35 AM - It Cannot Be Edited

Created By: Felisa Shirley On 05/19/2023 at 11:22 AM

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: STRATA BELLA HOME	FACILITY NUMBER: 198600216
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, 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 in which the toilet was not working and overflowed when fluched, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Caregiver Sally stated toilet will be fixed later today

Type B

Section Cited

CCR

80088(e)(3)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items. 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 in which the stove did not have knobs to turn the fire on which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 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:

Stephanie Cifuentes

LICENSING EVALUATOR NAME:

Felisa Shirley

LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

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