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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601824
Report Date: 07/02/2024
Date Signed: 07/02/2024 01:08:14 PM


Document Has Been Signed on 07/02/2024 01:08 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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: 6DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Anchie Reyes, AdministratorTIME COMPLETED:
01:27 PM
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On 07/02/2024, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARES Inspection Tool. LPA met with Anchie Reyes, Administrator (S1) 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 bedrooms, two (2) common bathrooms, living room, dining room, kitchen, detached garage and outside shaded patio area with table and chairs.
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 110.5 degrees F. and a comfortable temperature of 69.8 degrees F was maintained in the facility.
LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Medications were centrally stored, locked and inaccessible to residents. Storage areas for sharps and personal hygiene were observed and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly, with additional freezer stored in detached garage. The facility has two (2) fire extinguishers that were both fully charged, as of 07/17/2023. A working landline telephone remains available.
LPA observed First Aid Kit was maintained. The last emergency disaster drill was conducted on 05/30/2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file, effective 03/10/2024 through 03/10/2025.
An audit of residents #1-#6 (R1-R6) service files and medication administration record (MAR) and staff #1-#3 (S1-S3) personnel files revealed to be complete.

Report continues, see LIC809C.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELLA GARDENS
FACILITY NUMBER: 198601824
VISIT DATE: 07/02/2024
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During today's visit, there were no deficiencies cited.

An exit interview was conducted with Anchie Reyes, Administrator (S1) and a copy of this report was provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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