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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601824
Report Date: 08/16/2022
Date Signed: 08/16/2022 02:40:18 PM


Document Has Been Signed on 08/16/2022 02:40 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: 3DATE:
08/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Jenny Bee Estrella TIME COMPLETED:
01:47 PM
NARRATIVE
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On 08/16/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with caregiver Jenny Bee Estrella and explained the purpose of the visit.

During a case management annual continuation inspection visit on 08/01/22, LPA and was informed that resident #1 (R1) who was on hospice care had expired on 07/31/22. The assistant administrator stated the licensee would be sending a Death Report LIC624-A will be submitted to Community Care Licensing Department.

As of 08/16/22, the Licensee has failed to notify (CCLD) of this incident with a Death Report LIC624-A for (R1). It's been passed (7) days since the incident. The licensee violates 87211 Title 22 Regulations Reporting Requirements.

California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D).

An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Jenny Bee Estrella.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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 08/16/2022 02:40 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: 08/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2022
Section Cited

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87211 Reporting Requirements (a) licensee shall furnish to the licensing agency such reports as the Department... (1) A written report shall be submitted to the licensing agency... within seven days..(A) Death of any resident from any cause regardless of where the death occurred...
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This requirement is not met as evidence by:
Based on interview with licensee, Licensee failed to report incident with resident R1 admitted to hospital for change of health condition. This violation possesses a potential Health and Safety risk to residents in care.
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
LIC809 (FAS) - (06/04)
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