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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601824
Report Date: 07/30/2022
Date Signed: 07/30/2022 07:53:45 PM


Document Has Been Signed on 07/30/2022 07:53 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:BELLA GARDENSFACILITY NUMBER:
198601824
ADMINISTRATOR:DARYLLEN STONEFACILITY TYPE:
740
ADDRESS:2218 CONQUISTA AVENUETELEPHONE:
(562) 900-5208
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: 4DATE:
07/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Anchie ReyesTIME COMPLETED:
05:30 PM
NARRATIVE
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On 07/30/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with assistant administrator Anchie Reyes and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for two (2) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 106.9 F. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. The facility has two (2) fire extinguishers that were charged. A working landline telephone remains available.

Evaluation Report Continues on LIC 809-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2022
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 07/30/2022 07:53 PM - It Cannot Be Edited

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: BELLA GARDENS
FACILITY NUMBER: 198601824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Resident #3 (R3) identified on hospice and admitted 06/14/22. The facility is only approved for (2) hospice waiver and is now operating with (3) hospice residents beyond the conditions and limitations specified on the license. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2022
Plan of Correction
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Licensee agrees to hospice waiver increase request to CCLD by correction date 08/08/22 understands that it is their responsibility to follow up on waiver requests and hospice residents should not reside at the facility until a hospice waiver is granted by CCL.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above in [3] out of [3] [(disefectant solution, buther knife and sharp scissors) identified accessible to residents with dementia. The violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Licensee will adhere to Title 22 Regulations 87309(a) and ensure that all hazardous items i.e. disenfectants, knifes and scissors are stored in locked cabinets and not accessible to residents in care. The violation will due on POC 08/01/22.

*This vioation was corrected during visit on 07/30/22.*

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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2022
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: BELLA GARDENS
FACILITY NUMBER: 198601824
VISIT DATE: 07/30/2022
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DEFICIENCIES:
During a health and safety inspection, LPA observed at 3:20 pm a disinfectant solution under the kitchen sink, a butcher knife, and a sharp scissor inside the dishwasher accessible to residents in care. During record review, LPA observed resident #3 admitted on 06/14/22 as a hospice resident. This exceeded beyond the conditions and limitations specified on the license. The facility is licensed for (2) hospice waivers and currently, the facility is operating with (3) hospice residents in care.

Due to time constraints, an annual continuation is required to complete a health and safety inspection and conduct Infection Control questionnaires.

Deficiencies are issued and an exit interview is conducted with Anchie Reyes. A copy of this report is provided along with the appeal rights.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3