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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601824
Report Date: 08/01/2022
Date Signed: 08/17/2022 10:22:39 AM

Document Has Been Signed on 08/17/2022 10:22 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: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:
08/01/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Anchie ReyesTIME COMPLETED:
04:01 PM
NARRATIVE
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On 08/01/22 Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management - annual continuation visit at this facility. Upon arrival at the facility, LPA greeted assistant administrator Anchie Reyes and conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection.

The facility has smoke detectors, and carbon monoxide that was operable in all resident's rooms and common areas. LPA reviewed Medication Administration Records (MAR) and it revealed to be accurate and maintained in order.

DEFICIENCIES:
LPA toured the inside and outside grounds of the facility. LPA identified at 1:20 pm resident #4 (R4) who is not on hospice care had full bed rails which is prohibited according to Postural Supports Regulations 87608. LPA reviewed service records for resident #2 (R2) who was admitted on 06/14/22 under hospice care and failed to notify CCL within five days of admittance according to Hospice Care Waiver Regulation 87632. The facility has not conducted a Fire/Earthquake Drill since 09/2021. This is a violation according to Care of Persons with Dementia Regulations 87705. The administrator is being cited according to Administrator's Qualifications Regulations 87405 resulting in multiple deficiencies cited.

INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident tests and vaccination results was conducted. The facility has an approved Mitigation Plan Report on file with CCLD. The facility submitted an Infection Control Plan for 2022 with CCLD.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2022
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 4
Document Has Been Signed on 08/17/2022 10:22 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/01/2022 at 12:58 PM
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: BELLA GARDENS
FACILITY NUMBER: 198601824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
CCR
87405(b)(2

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87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2 )Knowledge of and ability to conform to the applicable laws, rules and regulations.
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The licensee will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submitted by POC due date: 08/12/22
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This requirement was not met as evidenced by:
Based on interview and record reviews the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.
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Type B
08/12/2022
Section Cited
CCR87632(2)

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87632 Hospice Care Waiver
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services...
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Licensee will adhere to Title 22 87632 regulations and will ensure notify CCL of hospice residents in care. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/12/22.
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This requirement is not met as evidence by:
Based on interview with licensee, Licensee failed to report to CCL with resident R2 admitted at this facility as of 6/14/22. This violation possess 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 Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/17/2022 10:22 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/01/2022 at 01:34 PM
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: BELLA GARDENS
FACILITY NUMBER: 198601824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
CCR
87608(B)

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87608 Postural Supports (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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Licensee will adhere to the regulations 87608 and will remove full bed rails for R4. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/12/22.
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This requirement is not met as evidence by:
Based on interview with administrator, Licensee failed to show proof for full bed rails for (R4) who is not a hospice reisdent. This violation possess a potential Health and Safety risk to residents in care.
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*This citation was corrected during visit 08/01/22.*
Type B
08/12/2022
Section Cited
CCR87705(3)

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87705 Care of Persons with Dementia (3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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Licensee will adhere to the regulations 87705 and will conduct a fire/earthquake drill as required. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/12/22.
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This requirement is not met as evidence by:
Based on records review with the administrator, Licensee failed to show proof quarterly fire and eaarthquake drills are conducted. This violation possess 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 Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


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: 08/01/2022
NARRATIVE
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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 Anchie Reyes.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022
LIC809 (FAS) - (06/04)
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