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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804142
Report Date: 06/18/2024
Date Signed: 06/18/2024 03:33:05 PM

Document Has Been Signed on 06/18/2024 03:33 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LA BELLA MANORFACILITY NUMBER:
496804142
ADMINISTRATOR/
DIRECTOR:		KAMAU, JOYCE M.FACILITY TYPE:
735
ADDRESS:4339 PRINCETON WAYTELEPHONE:
(707) 206-2169
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 4CENSUS: DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Joyce Kamau, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:47 PM
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Licensing Program Analysts (LPA) Christi Coppo and Jacky Macias arrived unannounced to conduct a required Annual inspection and no one was present at the facility. LPAs called Administrator to inquire as to the location of residents and Admin. Admin stated residents are at day program and she was at the hospital with a resident from a different facility but could meet LPAs in 30 minutes. Administrator arrived at 1:45PM.

At approximately 1:50pm LPAs and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Hall closet containing cleaning supplies was locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sink accessible to residents in care measured at 114.5 and 114.8 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 4/29/2024. Smoke/Carbon Monoxide detectors located throughout the facility were present. Facility’s last quarterly disaster drill was conducted on 6/13/2024.

At approximately 2:15pm LPAs conducted a review of 3 resident records. All required documentation present.



Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LA BELLA MANOR
FACILITY NUMBER: 496804142
VISIT DATE: 06/18/2024
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Continued from 809...

At approximately 2:30pm LPAs conducted review of 2 staff records. All required documentation present. Admin explained current situation with retaining adequate staff that is a good fit with current residents. Admin agrees to inform LPA with updates in regards to employee retention. Admin is aware of the importance on maintaining adequate staffing.

Per LPAs and Admin conversation, Admin is not currently handling cash for residents.



At approximately 2:45pm LPAs and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet. Resident (R1) had current medications that were not listed on the Centrally Stored Medication Log (CSML) (deficiency cited, see 809D).

Joyce Kamau Administrator Certificate 7001073735 expires 5/3/2025. LPAs gave LIS print out with PIN for payment.

LPAs and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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Document Has Been Signed on 06/18/2024 03:33 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/18/2024 at 02:51 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LA BELLA MANOR
FACILITY NUMBER: 496804142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80070(b)(10)
Client Records
(b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that Resident (R1) had current medications that were not listed on the Centrally Stored Medication Log (CSML), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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While at facility, Admin created Centrally Stored Medication Log listing all medications prescribed to R1. LPAs verified accurancy and advised Admin of importance of immediately recording all prescribed medications on Centrally Stored Medication Log upon receipt of medications. Deficiency cleared.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


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