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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602898
Report Date: 03/03/2025
Date Signed: 03/03/2025 03:06:22 PM

Document Has Been Signed on 03/03/2025 03:06 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:BELLA MANOR IIFACILITY NUMBER:
198602898
ADMINISTRATOR/
DIRECTOR:		ATENCIO, CHRISTINAFACILITY TYPE:
740
ADDRESS:7800 E. TULA STREETTELEPHONE:
(310) 953-5518
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 5DATE:
03/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Chistina Atencio, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 03/03/2025 at 08:35 am, Licensing Program Analyst (LPA) Zina Brown an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one year inspection. LPA met with Chistina Atencio, Administrator and the purpose of the visit was discussed. Facility is licensed to serve six (6) non-ambulatory residents age range 60 and over in which one may be bedridden. Three (3) residents are diagnosed with dementia, and all six (6) resident are on hospice (waiver approved on 10/31/2024 for six (6) residents. None of the residents are receiving home health. The facility does not handle any of the residents’ money. The facility has liability insurance with James River Insurance (NACI #41394) policy # 00156516-0 effective 08/17/2024 - 08/17/2025 (occurrence $1,000,000/general aggregate $3,000,000). The facility annual fees ($495) were paid on 01/21/2025.

The home is a single story home consisting of: (4) resident bedrooms, (2) Full bathroom, den, living room, kitchen with dining area, laundry room (by the kitchen) and backyard with an outdoor shaded patio area. LPA toured the 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 measured at 117.1 F (in kitchen), 115.5 F (in bathroom #1 and 117.6 (in bathroom #2). Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Report continues on LIC 809-C.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELLA MANOR II
FACILITY NUMBER: 198602898
VISIT DATE: 03/03/2025
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Between the hours of 10:11 am -11:20 am, LPA conducted a records review of (5) client records, (5) staff records, (0) clients Personal & Incidental Records and reviewed the facility disaster plan. Between the hours of 9:01 am - 9:25am, LPA reviewed (5) Client Medication Administration Records and did not observed any discrepancies at the time of visit. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA observed the following not in compliance.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. The last disaster drill was conducted 01/06/2025.

During today’s visit no discrepancies were observed.

Exit interview conducted with Administrator Christina Atencio, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
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