198320288-7-28-2022-11-AS-LMOA-CGS75M-20220728212144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320288
Report Date: 07/28/2022
Date Signed: 07/28/2022 09:22:15 PM

Document Has Been Signed on 07/28/2022 09:22 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BELLA MANOR		FACILITY NUMBER:	198320288
ADMINISTRATOR:	ALCANTARA, CHARMAINE		FACILITY TYPE:	740
ADDRESS:	20359 DONORA AVE		TELEPHONE:	(310) 371-8775
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 6		CENSUS: 5	DATE:	07/28/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	CHARESA REYES		TIME COMPLETED:	01:45 PM

NARRATIVE

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On 7/28/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an announced visit to this home. Upon arrival, LPA called the facility to conduct a risk assessment. LPA spoke with Licensee Christina Atencio who confirmed the facility is Covid-19 free. LPA met with Applicant Charesa Reyes who assisted with the visit. The purpose of the visit was explained.

An application was submitted to CCLD on 4/1/2022 for a Change of Ownership for a Residential Care Facility for the Elderly. The applicant requested a capacity of six (6) individuals of which five (5) are non-ambulatory and one (1) is bedridden. There are currently five (5) residents and two (2) caregivers present during the visit.
Structure:
The facility is a one-story house located in a residential neighborhood and consists of five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, two (2) car garage, receiving room, family room, dining area, and kitchen. Bedroom #1 is designated and approved for a bedridden resident. The facility is clean, sanitary, and in good repair. Protective devices are in place to include non-slip material on rugs. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. The facility temperature is between 68 degrees and 85 degrees.

Bedrooms (Residents):

All resident bedrooms include (1) bed, one (1) chair, one (1) nightstand, and one (1) table lamp. Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath, or toilet.

Evaluation Report Continued in LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA MANOR	FACILITY NUMBER: 198320288
	VISIT DATE: 07/28/2022

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Bedrooms (Staff):
There is one (1) staff bedroom.

Bathrooms:
The home has three (3) bathrooms of which one (1) bathroom is dedicated for staff. All resident bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in a cabinet in the garage.

Emergency Phone Numbers, Exit Plan & Menu:
The exit plan and menu are posted and readily available for review throughout the home. There is one (1) fire extinguisher located in the dining area. A telephone line is available in the kitchen (310-371-8775). Emergency supplies and Personal Protective Equipment supplies are stored in the garage. The applicant’s Mitigation Plan was approved on 2/26/2021.

Food Service:
All kitchen areas are clean and free of litter, rodents, vermin, and insects. The refrigerator and freezer are clean and of adequate size. The freezer is maintained at 0 degrees Fahrenheit and the refrigerator is below the required maximum of 40 degrees Fahrenheit. A two (2) day supply of perishable foods and a seven (7) day supply of non-perishable food were observed. All equipment, appliances, dishes, and utensils are clean and well maintained.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space are operable.

Toxins:
All toxins are locked and stored under the kitchen sink cabinet.

Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA MANOR	FACILITY NUMBER: 198320288
	VISIT DATE: 07/28/2022

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Water Temperature:
The water temperature is 110.3 degrees Fahrenheit in the common resident bathroom.

Medications, First-Aid Kit & Book:
A first aid kit is stored in a locked cabinet which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to clients. The client's medications are stored in a locked cabinet in the dining area.

Clients & Staff Files:
The applicant will not be handling the cash resources of the resident. Records of staff and residents are stored in a locked cabinet in the dining area.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, bingo and other recreational materials for the residents’ use all stored in the family room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the property.

Fire clearance:
A Fire Clearance inspection was conducted on 4/27/2022 with approval for a capacity of six (6) individuals of which five (5) are non-ambulatory and one (1) is bedridden.

Component III:
The applicant completed the Comp III training during today’s visit.

An exit interview was conducted, and a copy of this report has been furnished to Applicant Charesa Reyes. LPA Montoya will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

END OF REPORT

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC809 (FAS) - (06/04)

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