Bella Gardens

Type of visit: Required - 1 Year

On 07/03/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Anchie Reyes and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, two (2) common bathrooms, living room, dining room, kitchen, detached garage and outside shaded patio area with table and chairs. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 108.3 F and a comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene were observed and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly with additional freezer stored in detached garage. The facility has two (2) fire extinguishers that were both fully charged. A working land line telephone remains available. During today's visit, there was one deficiency cited, see LIC809-D. An exit interview was conducted with Anchie Reyes, Administrator, appeal rights and a copy of this report were provided.the state’s words, verbatim · CDSS document, Jul 3, 2023

Type of visit: Case Management - Deficiencies

On 08/16/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with caregiver Jenny Bee Estrella and explained the purpose of the visit. During a case management annual continuation inspection visit on 08/01/22, LPA and was informed that resident #1 (R1) who was on hospice care had expired on 07/31/22. The assistant administrator stated the licensee would be sending a Death Report LIC624-A will be submitted to Community Care Licensing Department. As of 08/16/22, the Licensee has failed to notify (CCLD) of this incident with a Death Report LIC624-A for (R1). It's been passed (7) days since the incident. The licensee violates 87211 Title 22 Regulations Reporting Requirements. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D). An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Jenny Bee Estrella.the state’s words, verbatim · CDSS document, Aug 16, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Aug 19, 2022

87211 Reporting Requirements (a) licensee shall furnish to the licensing agency such reports as the Department... (1) A written report shall be submitted to the licensing agency... within seven days..(A) Death of any resident from any cause regardless of where the death occurred... This requirement is not met as evidence by: Based on interview with licensee, Licensee failed to report incident with resident R1 admitted to hospital for change of health condition. This violation possesses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2022

Plan of correction: Licensee will adhere to the regulations and will ensure any changes in resident's health condition or death will be reported to CCLD. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/19/22

Type of visit: Case Management - Annual Continuation

On 08/01/22 Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management - annual continuation visit at this facility. Upon arrival at the facility, LPA greeted assistant administrator Anchie Reyes and conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. The facility has smoke detectors, and carbon monoxide that was operable in all resident's rooms and common areas. LPA reviewed Medication Administration Records (MAR) and it revealed to be accurate and maintained in order. DEFICIENCIES: LPA toured the inside and outside grounds of the facility. LPA identified at 1:20 pm resident #4 (R4) who is not on hospice care had full bed rails which is prohibited according to Postural Supports Regulations 87608. LPA reviewed service records for resident #2 (R2) who was admitted on 06/14/22 under hospice care and failed to notify CCL within five days of admittance according to Hospice Care Waiver Regulation 87632. The facility has not conducted a Fire/Earthquake Drill since 09/2021. This is a violation according to Care of Persons with Dementia Regulations 87705. The administrator is being cited according to Administrator's Qualifications Regulations 87405 resulting in multiple deficiencies cited. INFECTION CONTROL: During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident tests and vaccination results was conducted. The facility has an approved Mitigation Plan Report on file with CCLD. The facility submitted an Infection Control Plan for 2022 with CCLD. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D). An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Anchie Reyes.the state’s words, verbatim · CDSS document, Aug 1, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(b)(2 · Plan of correction due date: Aug 12, 2022

87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2 )Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on interview and record reviews the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2022

Plan of correction: The licensee will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submitted by POC due date: 08/12/22

From the deficiency page — Deficiency type: Type B · Section cited: CCR87632(2) · Plan of correction due date: Aug 12, 2022

87632 Hospice Care Waiver (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services... This requirement is not met as evidence by: Based on interview with licensee, Licensee failed to report to CCL with resident R2 admitted at this facility as of 6/14/22. This violation possess a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2022

Plan of correction: Licensee will adhere to Title 22 87632 regulations and will ensure notify CCL of hospice residents in care. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/12/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(B) · Plan of correction due date: Aug 12, 2022

87608 Postural Supports (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidence by: Based on interview with administrator, Licensee failed to show proof for full bed rails for (R4) who is not a hospice reisdent. This violation possess a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2022

Plan of correction: Licensee will adhere to the regulations 87608 and will remove full bed rails for R4. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/12/22. *This citation was corrected during visit 08/01/22.*

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(3) · Plan of correction due date: Aug 12, 2022

87705 Care of Persons with Dementia (3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement is not met as evidence by: Based on records review with the administrator, Licensee failed to show proof quarterly fire and eaarthquake drills are conducted. This violation possess a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2022

Plan of correction: Licensee will adhere to the regulations 87705 and will conduct a fire/earthquake drill as required. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/12/22.

Type of visit: Required - 1 Year

On 07/30/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with assistant administrator Anchie Reyes and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 106.9 F. A comfortable temperature of 73 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. The facility has two (2) fire extinguishers that were charged. A working landline telephone remains available. Evaluation Report Continues on LIC 809-C DEFICIENCIES: During a health and safety inspection, LPA observed at 3:20 pm a disinfectant solution under the kitchen sink, a butcher knife, and a sharp scissor inside the dishwasher accessible to residents in care. During record review, LPA observed resident #3 admitted on 06/14/22 as a hospice resident. This exceeded beyond the conditions and limitations specified on the license. The facility is licensed for (2) hospice waivers and currently, the facility is operating with (3) hospice residents in care. Due to time constraints, an annual continuation is required to complete a health and safety inspection and conduct Infection Control questionnaires. Deficiencies are issued and an exit interview is conducted with Anchie Reyes. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Jul 30, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst, (LPA) Jade Jordan conducted an unannounced Inspection Control Annual visit On 06/17/21 . The facility is licensed for six (6) non-ambulatory residents. LPA Jordan and Administrator toured the physical plant, checked food service, reviewed staff records and reviewed resident records. The home consists of 5 resident bedrooms, 1 staff bedroom, 2 bathrooms, living room, dining room, den 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. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Administrator certificate expires 01/11/22, and has a valid CPR certificate on file. The 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 and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. First Aid kit was available. Outside grounds were toured and one fountain was observed. Walkways around the home were clear of hazards. The home has a detached Garage, that is used for storage and laundry. It is inaccessible to residents in care. The Last fire drill was conducted in March of 2021. LPA observed staff wearing masks, Visitor Log /Symptom screening Log, Designated isolation room, required Covid-19,Postings, 30 day supply of PPE and other required documents, including phone numbers are posting as mandated by the DPH and CCLD. No citations were issued during visit, a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Jun 17, 2021