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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601824
Report Date: 07/03/2023
Date Signed: 07/03/2023 11:51:24 AM


Document Has Been Signed on 07/03/2023 11:51 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: 5DATE:
07/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Anchie Reyes - AdministratorTIME COMPLETED:
12:04 PM
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On 07/03/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with 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 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 108.3 F and a comfortable temperature 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 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. A working land line telephone remains available.

During today's visit, there was one deficiency cited, see LIC809-D. An exit interview was conducted with Anchie Reyes, Administrator, appeal rights and a copy of this report were provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
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 07/03/2023 11:51 AM - 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: 07/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 screen located in doorway of bedroom number three (3) shall be re-screened in order to prevent any insects from entering the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2023
Plan of Correction
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LPA and Administrator have agreed that the screen shall be repaired within the next seven (7) days and that media evidence (photo/scan) will be submitted via email (mario.leon@dss.ca.gov) on, or prior to, the POC due date which is 07/10/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
LIC809 (FAS) - (06/04)
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