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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320288
Report Date: 08/24/2024
Date Signed: 08/24/2024 12:55:36 PM

Document Has Been Signed on 08/24/2024 12:55 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BELLA MANORFACILITY NUMBER:
198320288
ADMINISTRATOR/
DIRECTOR:		ALCANTARA, CHARMAINEFACILITY TYPE:
740
ADDRESS:20359 DONORA AVETELEPHONE:
(310) 371-8775
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 6DATE:
08/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:House Manager/Caregiver - Gavina Fuentes TIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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On 08/24/2024 at around 10:30 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with House Manager Gavina Fuentes. LPA explained the purpose of the visit and was accompanied by a staff inside and outside the facility during this inspection.

This facility is licensed to serve 6 non-ambulatory residents ages 60 and above, of which 1 maybe bedridden, and 4 maybe on hospice.
A total of 6 residents are currently residing in this facility.
The Annual Licensing Fees are current.

The facility is a one-story house located in a residential street. The home consists of 4 resident bedrooms, 1 staff bedroom, receiving room/kitchen/dining/living room area, 1 attached garage, and 1 backyard patio area with shaded seating.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BELLA MANOR
FACILITY NUMBER: 198320288
VISIT DATE: 08/24/2024
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Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxics were kept in locked storage cabinet.

LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last fire drill was conducted on 08/02/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is a fire extinguisher in the kitchen area and it was last serviced on 08/01/2024. There is a videoconferencing device dedicated for client use in the area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BELLA MANOR
FACILITY NUMBER: 198320288
VISIT DATE: 08/24/2024
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4 out of 4 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.
5 resident records were reviewed and, 5 out of 5 resident records had required documentation.

No deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted, and a copy of this report was left with the House Manager.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2024
LIC809 (FAS) - (06/04)
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