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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003889
Report Date: 03/12/2024
Date Signed: 03/12/2024 01:58:17 PM

Document Has Been Signed on 03/12/2024 01:58 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:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Jose Roberto dela Cruz - Designated Administrator
Lucita Guillermo - Direct Support Professional(DSP)		TIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was allowed entry by Lucita Guillermo/Direct Support Professional(DSP) and explained the purpose of today's visit. The Administrator, Johnette Bellosillo is out of the country, but the designated Administrator, Jose Roberto dela Cruz arrived to assist 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: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The staff stated that they use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Bathrooms have hand soap, paper towel and toilet paper. 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. Currently, there are three (3) clients living in the facility. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. Laundry area is in the hallway. There is a fire place in the living room that is covered and inaccessible to clients. One (1) fire extinguisher was observed in the kitchen and appeared to be full and was last serviced on 04/04/2023. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 118.4 deg F in bathroom #1, and 116.7 deg F in bathroom #2. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. There is camera in the front yard only.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid and expires on 03/04/2025. Surety Bond in the amount of $3000 is in effect until 01/20/2025. Per the designated Administrator, the last Fire Drill was conducted recently, but there was no proof presented as they could not locate the file. The fire clearance is approved for (3) ambulatory, restricted condition clients.
*****Refer to LIC 809C for the continuation of this report.*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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: 03/12/2024
NARRATIVE
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Staffing: There is sufficient staffing at the facility. The Administrator, Johnette Bellosillo is still waiting for her Administrator certificate. Her certificate (#6023643735) expired on 01/23/2023, and renewal along with CEU's were submitted on 12/10/2022. Administrator's HIV/AIDS Training Certificate shows completed on 6/24/2022. Designated Administrator, Jose Roberto Dela Cruz's Administrator certificate expired on 02/14/2023. Renewal was submitted on 01/09/2023, and he has not received the current certificate. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (3) staff files including the Administrator. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current.
Client Rights-Information: Client personal rights are posted. Per designated Administrator, facility provides internet services to all clients and have access to the facility phone. Per DSP Guillermo, none of the clients have their own personal cell phones. There is one (1) tablet being shared by all (3) clients in the facility.
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 and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator.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.
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. LPA observed that the Medication Administration Record (MAR) was initialed on 3/12/2024 showing that C1 was administered an oral rinse at 7am, however, the oral rinse has been finished and not been refilled for a week.
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 Designated Administrator, Jose Roberto dela Cruz.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/12/2024 01:58 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/12/2024 at 01:34 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in that C1's oral rinse (Chlorhexidine Gluc 0.12%) has been finished and not been refilled, however, the Medication Administration Record (MAR) was initialed showing that C1 was administered the rinse daily at 7am which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 03/13/2024
Plan of Correction
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The designated Administrator shall re-train the staff on Medication training and completing MARs. Proof of completed training will be submitted to LPA/CCL by POC due date.
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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/12/2024 01:58 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/12/2024 at 01:34 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

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 which the designated Administrator stated that the last Fire Drill was conducted recently, but there was no proof presented as they could not locate the file which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/22/2024
Plan of Correction
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Administrator will submit the latest fire drill conducted with staff to LPA/CCL by POC due date.
Type B
Section Cited
CCR
80070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator/ licensee did not comply with the section cited above in that the Physician's report stated that Client #1 is non-ambulatory, however facility is licensed to care for ambulatory clients only which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Administrator will submit a current medical assessment for C1 indicating his correct ambulatory status. Proof shall be submitted to CCL/LPA by 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: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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