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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602898
Report Date: 03/09/2022
Date Signed: 03/09/2022 04:48:44 PM

Document Has Been Signed on 03/09/2022 04:48 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 IIFACILITY NUMBER:
198602898
ADMINISTRATOR:ATENCIO, CHRISTINAFACILITY TYPE:
740
ADDRESS:7800 E. TULA STREETTELEPHONE:
(310) 953-5518
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 4DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Christina Atencio TIME COMPLETED:
04:30 PM
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On 03/09/22 Licensing Program Analyst (LPA) Jade Jordan Conducted an Unannounced Annual Inspection, with an emphasis on Infection Control. LPA was met by Facility Administrator Christina Atencio and the purpose of the visit was explained.

Upon Entry LPA observed Covid-19 postings on the exterior of the facility, and was screened for Covid 19, including a Temperature check.

The Facility is licensed for 6 non-ambulatory residents.
The interior consists of 4 resident bedrooms of which 1 is shared, 1 Staff Bedroom, 1 Living room, 1 dinning room, 1 den, Laundry space, 2 bathrooms , and kitchen.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature properly measured at 111.0. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Administration certificate expires 11/13/2022.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. All cleaning solutions, hazardous items, and medications were securely locked. A fire extinguisher was available and fully charged. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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 II
FACILITY NUMBER: 198602898
VISIT DATE: 03/09/2022
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The facility is following their mitigation plan. LPA observed a minimum of 30 day supply of PPE, which included N95 masks, gowns, face shields, surgical masks, hand sanitizer, soap, disinfectant, paper towels
trash can with lid. Fit testing was completed by staff on 04/02/21. All staff a fully vaccinated and have documentation in their staff files. A daily Covid log is taken for visitors ,staff , and residents.

No deficiencies were noted during this visit.

A copy of this report was provided, and an exit interview was conducted.


SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
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