198600775-1-28-2026-28-AS-EMAT-DQRR4D-20260128114121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600775
Report Date: 01/28/2026
Date Signed: 01/28/2026 11:41:35 AM

Document Has Been Signed on 01/28/2026 11:41 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	STRATA BELLA (NORWALK) CORPORATION		FACILITY NUMBER:	198600775
ADMINISTRATOR/ DIRECTOR:	RUDY DEOCAMPO		FACILITY TYPE:	735
ADDRESS:	13213 FLALLON AVENUE		TELEPHONE:	(562) 864-9803
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 4		CENSUS: 3	DATE:	01/28/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Administrator- Jon de la Cruz		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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Licensing Program Analysts (LPAs) Elena Mallett conducted an unannounced initial Case Management Visit to follow up on a Death Report that was emailed to the Department on 01/22/2026 LPAs met with Staff 2 (S2) who contacted Administrator Jon de la Cruz and explained the reason for the visit. Administrator de la Cruz and Licensing Program Analyst (LPA) Bonnie Tao joined the visit shortly after.

On 01/21/2026 Licensing received a Death Report for Client 1(C1). C1 passed away on 01/21/2026 at 12:23 PM after vomiting and becoming unresponsive. Emergency Responders were called but unable to save C1. Cause of death and Death Certificate are pending.

During the visit, LPA Mallett interviewed administrator, staff#1 (S1) and staff#2 (S2). C1’s file was reviewed.

LPAs obtained the following:

Staff and Client rosters,
C1's Face Sheet,
Facility Visitor Log Nov 2025-Jan 2026 and Home Health Nurse Visitor Log Dec 2025- Jan2026
Staff notes related to C1 (12/27/25-01/21/26)
Home Health Care Plan and Physician's Orders.
Physician Report dated 07/07/25,
Harbor Regional Center IPP dated 12/04/25,
C1’s LIC 601 Personal Identification and Emergency Information and ID
C1’s Medication Administration Records (MAR) - December 2025 and January 2026,
C1’s Vista Specialty Hospital Nurses Notes ( Skilled Nursing Facility),

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STRATA BELLA (NORWALK) CORPORATION	FACILITY NUMBER: 198600775
	VISIT DATE: 01/28/2026

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11. C1’s Menus for January and February and

12. C1’s CPR/ First Aid card for S1.

13. C1’s Home Health nurses’ contact information

14. C1’s Incident reports dated 11/19/25 and 01/04/26

LPA's toured the physical plant and C1's room and no health and safety risks were observed.

Administrator stated coroner report would not be available due to the primary doctor will sign C1’s death certificate. Administrator stated Death Certificate will be provided to Licensing upon receipt.

Exit interview was conducted with Administrator Jon de la Cruz and a copy of LIC 809 report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC809 (FAS) - (06/04)

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