198602898-1-20-2022-11-AS-JHAD-CB9RSG-20220202121640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602898
Report Date: 01/18/2022
Date Signed: 01/20/2022 07:39:05 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2022 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220113075855

FACILITY NAME:	BELLA MANOR II		FACILITY NUMBER:	198602898
ADMINISTRATOR:	ATENCIO, CHRISTINA		FACILITY TYPE:	740
ADDRESS:	7800 E. TULA STREET		TELEPHONE:	(310) 953-5518
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 6	DATE:	01/18/2022
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Christina Atencio		TIME COMPLETED:	03:46 PM

ALLEGATION(S):

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Staff are not following proper protocol for COVID-19.
Staff failed to provide resident with privacy.
Staff failed to provide a safe and comfortable environment.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegation listed above. LPA met with Christina Atencio the facility administrator and the purpose of the visit was explained.
The investigation consisted of the following: On 01/18/2022 LPA Coronel LPA interviewed the administrator 2 staff and 6 residents. LPA requested copies of and reviewed facility records and resident R1 and R2’ resident records.

The investigation revealed the following: Regarding the allegation “Staff are not following proper protocol for COVID-19.” During todays visit LPA observed that staff were conducting COVI-19 screenings at the entrance, which included symptom checks and verification of COVID-19 Vaccination. Staff S1 stated that if an essential visitor is not able to present proof of vaccination then I will call the administrator for further assistance. The administrator stated that “I will call that essential visitors office to get verification of their vaccination. We are following the most recent guidance provided by the state...”

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220113075855

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 II	FACILITY NUMBER: 198602898
	VISIT DATE: 01/18/2022

NARRATIVE

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During todays visit LPA conducted a review of the California Department of Public Health’s Requirements for Visitors in Acute Health Care and Long-Term Care Settings dated 12/31/2021 which orders the following:” Effective 01/07/2021… Visitation shall be permitted only in accordance with this Order….B. …Adult and Senior Care Residential Facilities must either: (1) for indoor visitation, verify visitors are vaccinated, have had all recommended doses… and provide evidence of a negative SARS-CoV-2 test within one day of visitation for antigen tests, and within two days of visitation for PCR tests; OR (2) permit only outdoor visitation for those that do not meet all the requirements in Section B (1). LPA did not observe exemptions for home health nurses. Regarding the allegation " Staff are not following proper protocol for COVID-19" Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Regarding the allegation: “Staff failed to provide resident with privacy.” During today’s visit LPA observed that resident R1 is staying in a private bedroom and R2 is staying in a shared bedroom, LPA observed a curtain placed which provides privacy between R2 and their roommate. During interviews staffs S1, S2 and S3 stated that they allow all visitors privacy during their visits with residents, S1 stated that “We only provide assistance when the nurses asks, we step out of the room and close the door.” When asked if they were being provided privacy during nurse visits, residents R1, R2, R5 and R6 were not available to provide answers, residents R3 and R4 said “Yes” R3 stated “I have no complaints, S2 takes good care of me.” Regarding the allegation: “Staff failed to provide resident with privacy.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Regarding the allegation: “Staff failed to provide a safe and comfortable environment.” During todays visit LPA observed small sized trash cans with plastic bag liners located next to all residents’ bed. Staff S2 stated that “We always have trash cans available and we empty the trash cans after each use. Also essential visitors can always ask us for assistance and we will help them dispose of trash” During todays visit LPA did not observe any resident being visibly uncomfortable, R3 and R4 stated that they felt good about the way they were treated by staff residents R1, R2, R5 and R6 were not available to provide interviews. Regarding the allegation: “Staff failed to provide a safe and comfortable environment.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
An exit interview was conducted. A copy of this report was provided to with Christina Atencio the facility administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

LIC9099 (FAS) - (06/04)

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