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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003889
Report Date: 04/22/2023
Date Signed: 04/22/2023 02:30:11 PM

Document Has Been Signed on 04/22/2023 02:30 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:STRATA BELLA HOMEFACILITY NUMBER:
306003889
ADMINISTRATOR:JOHNETTE B. BELLOSILLOFACILITY TYPE:
735
ADDRESS:9350 HIGHDALE STREETTELEPHONE:
(562) 866-9838
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 3CENSUS: 3DATE:
04/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Johnette BellosilloTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was screened and allowed entry by Lucita Guillermo/Direct Support Professional(DSP). LPA explained the purpose of today's visit. At 11:00am, Administrator Johnette Bellosillo arrived and assisted LPA with the inspection.
The facility is licensed to serve 3 Ambulatory Developmentally Disabled Adults, Restricted Health Conditions ages 18 through 59. Current census is (3) ambulatory. All clients residing at this facility receive case management services provided by Harbor Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies. Facility has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Physical Plant & Environment Safety: This facility consists of (3) bedrooms (2) full bathrooms, living/activity room, kitchen, dining area, and detached garage. Smoke alarms were tested and operable. Fire extinguisher appeared to be full and was last serviced on 04/04/2023. Carbon monoxide tested and operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured 115.8* in the kitchen, 74.8* in bathroom #1, and 116.3* in bathroom #2.

Operational Requirements: The fire clearance is approved for (3) ambulatory, restricted condition clients. Last Fire Drill was conducted on 01/21/2023.

Staffing: There is sufficient staffing at the facility. The Administrator, Johnette Bellosillo is still waiting for her curent certificate. Her Administrator certificate (#6023643735) expired on 01/23/2023. Renewal along with CEU's were submitted on 12/10/2022. Administrator's HIV/AIDS Training Certificate shows completion on 6/24/2022. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: STRATA BELLA HOME
FACILITY NUMBER: 306003889
VISIT DATE: 04/22/2023
NARRATIVE
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Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1. Staff have sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Per Administrator, none of the clients have their own personal cell phones. Per Administrator, all (3) clients have their own tablet, purchased by the clients personally.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable, but insufficient supplies of non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). There are no clients with special diets residing at this facility, but (2) clients need to have their food pureed. Pesticides and cleaning supplies are kept away from the food preparation areas (locked in a cabinet under the kitchen sink). Plates, cups and utensils are kept cleaned and stored properly. LPA observed that the dishwasher was broken and inoperable.

Health Related Services The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C3. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed. No discrepancies noted.

Incidental Medical Services: Per Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.

Emergency Intervention : Not-Applicable.


Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to Administrator, Johnette Bellosillo.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/22/2023 02:30 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/22/2023 at 01:20 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STRATA BELLA HOME
FACILITY NUMBER: 306003889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator/Licensee did not comply with the section cited above in that the Administrator/Licensee has not submitted an Infection Control Plan which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/03/2023
Plan of Correction
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The Administrator agreed to submit an updated infection Control Plan. Additionally, the Administrator/Licensee will review the PINs related to the plan and submit a signed statement that the PINs has been read, reviewed and understood on or before the POC due date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the Administrator/ licensee did not comply with the section cited above in which
the en-suite bathroom in Bedroom #1 did not deliver hot water. Hot water readings at 11:00am were 68.7*/ 71.6* / 74.8* all tests were checked in the span of 10 minutes, which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/05/2023
Plan of Correction
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Administrator/Licensee will ensure that the hot water temperature is maintained between 105 degrees F - 120 degrees F and will submit the receipt/service report from the plumber showing that the hot water temperature has been regulated and fixed. POC must be submitted to CCLD/LPA by the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/22/2023 02:30 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/22/2023 at 01:20 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STRATA BELLA HOME
FACILITY NUMBER: 306003889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator/Licensee did not comply with the section cited above in which the toilet in Bathroom # 1 is out of order and not filling water in the flush tank properly. which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/05/2023
Plan of Correction
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Administrator/Licensee will submit proof such as service report/invoice from the plumber on or before the POC due date to CCLD/LPA.
Type B
Section Cited
CCR
85088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator/Licensee did not comply with the section cited above in which the cushion and upholstery of the cream colored leather chair in bedroom #2 is worn-out and needs to be replaced, which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/05/2023
Plan of Correction
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The Administartor will send proof to CCLD/LPA that the sofa has either been replaced or re-upholstered on or before the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/22/2023 02:30 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/22/2023 at 01:20 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STRATA BELLA HOME
FACILITY NUMBER: 306003889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator/Licensee did not comply with the section cited above in which the backyard/outdoor activity area does not provide a shaded area and/or patio umbrella which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/05/2023
Plan of Correction
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The Administartor/Licensee will submit photos of the patio umbrella to CCLD/LPA on or before the POC due date.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator/Licensee did not comply with the section cited above in which the non perishable items in stock are insufficient, which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/05/2023
Plan of Correction
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The Administrator agreed to purchase additional canned goods, fruits/desserts and vegetables. Administrator will submit proof of purchase/receipts to CCLD/LPA on or before the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2023


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