198602900-4-4-2025-28-AS-MCOA-DFERAG-20250404125106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602900
Report Date: 04/04/2025
Date Signed: 04/04/2025 12:51:20 PM

Document Has Been Signed on 04/04/2025 12:51 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	BELLA HOME CARE		FACILITY NUMBER:	198602900
ADMINISTRATOR/ DIRECTOR:	MANALANG, SHELLA		FACILITY TYPE:	735
ADDRESS:	11503 209TH STREET		TELEPHONE:	(562) 728-7200
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90715
CAPACITY: 4		CENSUS: 4	DATE:	04/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:13 AM
MET WITH:	Janina Gumanad, Direct Support Personnel		TIME VISIT/ INSPECTION COMPLETED:	12:55 PM

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	Licensing Program Analysts (LPAs) Mayra Cota and Blanca Gonzalez conducted an unannounced required annual visit. LPAs met with Janina Gumanad, Direct Support Personnel, and explained the reason for the visit. Administrator, Tricia Estrevillo, arrived shortly after. The facility is licensed to serve 4 developmentally disabled adults ages 18 to 59 years old of which two can be ambulatory and two can be non-ambulatory. The facility is operating within the scope of its license. Clients receive services through Harbor Regional Center. The facility is in a residential area of Lakewood. During the visit, LPAs and DSP staff toured the indoor and outdoor environment of the facility, reviewed client and staff files, and checked medication. The physical plant tour consisted of the living room/theater, kitchen and dining area, four client bedrooms, two full bathrooms, two closets in the main hallway, front and back patio and attached garage/laundry area. LPAs observed the following: Inside the home: Living room/theater furniture is in good repair. Activity items were observed in a cabinet and are accessible to clients. Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA HOME CARE	FACILITY NUMBER: 198602900
	VISIT DATE: 04/04/2025

NARRATIVE

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Kitchen appliances were clean and were operating at the time of the visit. Sharps are locked in a drawer and are inaccessible to clients.
Dining area has sufficient seating space for clients and furniture is in good repair.
Cleaning supplies and toxins are locked in a cabinet in the kitchen island.
Sufficient supply of 2 day perishable and 7 day non-perishable food was observed and additional emergency food supply was observed in the garage. Food stored in kitchen cabinets and in the refrigerator is labeled and kept within expiration limits.
Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and mattress pads. There is a closet in the hallway with extra clean linen, towels, and personal hygiene items for clients.
The water temperature was tested in both bathrooms and measured at 105.2-degrees F in bathroom 1- and 108.1-degrees F in bathroom 2 which is within the required 105 - 120 degrees F.
Combination smoke and carbon monoxide detectors were observed throughout the facility and were tested and working properly. There are two fire extinguisher located in the kitchen and the garage and were observed to be charged.
Last fire/safety drill was conducted on 3/20/25 and documented accordingly.
Doors leading to the outdoor environment observed to be equipped with safety chimes which were tested and working properly.
Client emergency call button observed, and operating accordingly.

Outdoor environment:

The front and backyard are well maintained and there are no pools or large bodies of water. Shaded and seating areas observed in the front and backyard. Patio furniture in front and backyard is clean and in good repair.
Passageways and exits are free of obstruction.
Storage shed in the backyard was observed to be locked and inaccessible to clients.
Back-up generator located in the backyard observed covered.

***Continues on 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA HOME CARE	FACILITY NUMBER: 198602900
	VISIT DATE: 04/04/2025

NARRATIVE

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Medication and record review:

Client medication and files are centrally stored in a locked cabinet in the kitchen, and staff files are kept locked in a cabinet in the garage.
Four client medications were reviewed.
Four client files were reviewed.
Four staff files were reviewed.
Several First Aid kits were reviewed and all had the required tools.
First Aid manual observed and is accessible to staff.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies noted during the visit, however, a technical advisory was given. Exit interview conducted with Tricia Estrevillo, Administrator and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC809 (FAS) - (06/04)

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