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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602900
Report Date: 03/14/2022
Date Signed: 03/14/2022 10:14:14 AM

Document Has Been Signed on 03/14/2022 10:14 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BELLA HOME CAREFACILITY NUMBER:
198602900
ADMINISTRATOR:MANALANG, SHELLAFACILITY TYPE:
735
ADDRESS:11503 209TH STREETTELEPHONE:
(562) 728-7200
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 4CENSUS: 4DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tricia Estrevillo - AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Administrator Tricia Estrevillo and explained the reason for the visit. The facility is licensed to serve 2 non-ambulatory and 2 ambulatory clients between the ages of 18 and 59. The facility is in a residential area. A tour of the single-story facility included the living room, dining area, kitchen, 4 client bedrooms, 2 bathrooms, attached garage, front yard, and backyard.

LPA Mora conducted the tour with Tricia Estrevillo and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen and in the refrigerator located in the garage. Sharps were observed locked in a kitchen cabinet. Chemical and cleaning solutions are kept locked in a kitchen cabinet. The First Aid kit is kept locked in a kitchen cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra linen were observed in the closet of each client bedroom. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a kitchen cabinet. All bedrooms have all required furniture, lighting, and bedding. Both bathrooms were observed with shower mats and hand bars for the non-ambulatory clients. The water temperature was tested and measured at 114.7 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and are fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. A carbon monoxide was observed in the dining area and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.
LPA reviewed medication for all four clients. Medications are documented properly and given as prescribed. Client and staff files were not reviewed in today’s visit. LPA observed administrator certificate for Tricia Estrevillo – 6057358735 with an expiration date of 10/01/2022.

(CONTINUED TO LIC 809C)

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BELLA HOME CARE
FACILITY NUMBER: 198602900
VISIT DATE: 03/14/2022
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Facility has 30 days supplies of Personal Protective Equipment in the garage. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.


Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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