<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602898
Report Date: 02/22/2024
Date Signed: 02/22/2024 11:39:37 AM


Document Has Been Signed on 02/22/2024 11:39 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:BELLA MANOR IIFACILITY NUMBER:
198602898
ADMINISTRATOR:ATENCIO, CHRISTINAFACILITY TYPE:
740
ADDRESS:7800 E. TULA STREETTELEPHONE:
(310) 953-5518
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:6CENSUS: 5DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Administrator Christina AtencioTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 02/22/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Christina Atencio as the purpose of the visit was explained. The facility is licensed for six (6) non-ambulatory residents of which (1) may be bedridden ages 60 and over. Facility has an approved hospice waiver for (4). Current facility census is (5). There are no facility fees due at this time, liability insurance is active.

The facility is a single-story structure located in a residential neighborhood and consists of the following: (5) resident bedrooms, (2) bathrooms, living room, dining room, family room used for activities, kitchen, washer and dryer area with linen storage, a backyard with table and chairs, and a detached garage that is used for storage. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F..Kitchen was inspected and observed to be clean and operational. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to residents, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of (3) staff records, (2) resident records, and (2) medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. (1) fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational. Landline and internet service was observed. The last fire was conducted on 01/01/24.During today’s visit no discrepancies were observed.

Exit interview conducted with Administrator Christina Atencio, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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 1