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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601824
Report Date: 07/11/2026
Date Signed: 07/11/2026 12:43:29 PM

Document Has Been Signed on 07/11/2026 12:43 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/
DIRECTOR:		DARYLLEN STONEFACILITY TYPE:
740
ADDRESS:2218 CONQUISTA AVENUETELEPHONE:
(562) 900-5208
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 6DATE:
07/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:59 AM
MET WITH:Anchie Reyes TIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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On July 11, 2026, 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. Currently, there are no hospice residents in care.

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 105.9 F. A comfortable temperature of 72 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
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/11/2026 12:43 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/11/2026 at 11:47 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BELLA GARDENS
FACILITY NUMBER: 198601824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(1-6)
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
(1) Statement of purposes and program goals.
(2) A copy of the Admission Agreement, containing basic and optional services.
(3) Statement of admission policies and procedures regarding acceptance of persons for services.
(4) Administrative organization.
(5) Staffing plan, qualifications and duties.
(6) Plan for training staff, as required by Health and Safety Code sections 1569.625, 1569.626, and 1569.69 and as specified in Section 87411, Personnel Requirements–General and Section 87705, Care of Persons with Dementia.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview and record review, the licensee did not comply with the section. LPA identified (5) resident rooms had surveillance cameras in each resident room. The facilty does not have this included in the Plan of Operation. This is violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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Licensee will comply with Title 22, Section 87208 (a)(1-6) and submit an updated Plan of Operation that includes the use of surveillance cameras in resident rooms. Additionally, the Licensee will submit a waiver for the use of surveillance cameras in residents' private rooms, along with a corresponding Plan of Operation. Proof of correction must be sent to attn: LPA Ernand Dabuet by fax 424-544-1016 by 07/31/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2026 12:43 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/11/2026 at 12:09 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BELLA GARDENS
FACILITY NUMBER: 198601824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1-2)
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements:
(1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.
(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA identified one side exterior gate with a pad lock. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2026
Plan of Correction
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Licensee will comply with Title 22 87705(f)(1-2) regulations. LIcensee will ensure that exterior gates do not have padlocks as as safety obstructions in case of emergency exits. Licensee will remove the padlock or request for fire inspection approval for the local fire department. Proof of correction must be sent to LPA Dabuet by 07/12/26.

*Correction was completed during the visit.
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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2026


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: 07/11/2026
NARRATIVE
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A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurate. The facility conducted Fire/Safety Drill on 05/01/26.

During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. Posters mandated for inspection control were posted.

An audit of residents #1-#6 (R1-R6) service records and staff #1-#6 (S1-S6) personnel records revealed to be complete. The facility has current liability Insurance policy # 0100230231-3 Effective 03/10/26 - 03/10/27 The facility is current on CCL annual dues. The facility has a current administrator's certificate for Anchie Reyes #7010807740 valid through 01/11/28.

DEFICIENCIES:
  • During a health and safety inspection, LPA observed at 11:30 am the exterior side gate with a padlock.
  • LPA observed all (5) residents rooms with surveillance cameras and the facility had no waiver request or updated plan of operation to include the use of cameras in private rooms.

Deficiencies are issued and an exit interview is conducted with Anchie Reyes. A copy of this report is provided along with the appeal rights.


NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2026
LIC809 (FAS) - (06/04)
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