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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601824
Report Date: 06/17/2021
Date Signed: 02/02/2022 08:15:26 AM

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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BELLA GARDENSFACILITY NUMBER:
198601824
ADMINISTRATOR:DARYLLEN STONEFACILITY TYPE:
740
ADDRESS:2218 CONQUISTA AVENUETELEPHONE:
(562) 900-5208
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: 5DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Anchie ReyesTIME COMPLETED:
01:36 PM
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Licensing Program Analyst, (LPA) Jade Jordan conducted an unannounced Inspection Control Annual visit On 06/17/21 . The facility is licensed for six (6) non-ambulatory residents. LPA Jordan and Administrator toured the physical plant, checked food service, reviewed staff records and reviewed resident records. The home consists of 5 resident bedrooms, 1 staff bedroom, 2 bathrooms, living room, dining room, den and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Administrator certificate expires 01/11/22, and has a valid CPR certificate on file.

The kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. First Aid kit was available. Outside grounds were toured and one fountain was observed. Walkways around the home were clear of hazards. The home has a detached Garage, that is used for storage and laundry. It is inaccessible to residents in care. The Last fire drill was conducted in March of 2021.

LPA observed staff wearing masks, Visitor Log /Symptom screening Log, Designated isolation room, required Covid-19,Postings, 30 day supply of PPE and other required documents, including phone numbers are posting as mandated by the DPH and CCLD.

No citations were issued during visit, a copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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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