198320288-10-9-2026-11-AS-JANO-DYPUYD-20261009155946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320288
Report Date: 10/09/2026
Date Signed: 10/09/2026 04:00:03 PM

Document Has Been Signed on 10/09/2026 04:00 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		FACILITY NUMBER:	198320288
ADMINISTRATOR/ DIRECTOR:	ALCANTARA, CHARMAINE		FACILITY TYPE:	740
ADDRESS:	20359 DONORA AVE		TELEPHONE:	(310) 371-8775
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 6		CENSUS: 6	DATE:	10/09/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Gavina Fuentes		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

NARRATIVE

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On 10/09/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced Required – 1 Year Inspection at the above-named facility. LPA met with Caregiver Gavina Fuentes and explained the purpose of the visit.

The facility is licensed to serve six non-ambulatory residents, age 60 and over, of which one may be bedridden in bedroom (1) only. The facility has an approved hospice waiver for four residents.

The facility is a single-story home consisting of four resident bedrooms, two bathrooms, a living room, kitchen with dining area, laundry room in the attached garage, and an outdoor shaded patio.

The department toured the entire inside and outside of the facility. Smoke and carbon monoxide detectors were operational. The fire extinguisher was present in the facility. Hot water measured 118 degrees Fahrenheit in restrooms. Facility temperature measured 77 degrees Fahrenheit. Hallways, exits, outdoor walkways, and the facility’s physical condition were inspected and cleared of obstructions.

Posting of the facility license, meal menu, Personal Rights, Ombudsman, and Complaint posters were observed in the facility. The department observed sufficient food supplies, linens, towels, toiletries, first aid supplies and manual, medication storage, and separation of cleaning supplies from food. Cell phone and video communication access, activities, and shaded outdoor seating were observed in the facility.

The department reviewed [5] resident records using LIC 858 and [5] staff records using LIC 859. Liability insurance expiring 04/01/27. Resident MAR records were reviewed along with bottled medications.

Please see (LIC809-C) for report continuation.

Ulysses Coronel
Jose Anguiano
	DATE: 10/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 10/09/2026 04:00 PM - It Cannot Be Edited

Created By: Jose Anguiano On 10/09/2026 at 01:31 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BELLA MANOR	FACILITY NUMBER: 198320288
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, on 10/09/2026 at approximately 9:00 AM, the licensee retained R1, identified as bedridden in physician’s report, in bedroom #4 instead of bedroom #1 as required by the approved fire clearance. Bedroom #1 was occupied by R2, identified as non-ambulatory in physician’s report. This violation poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/10/2026
	Plan of Correction
1 2 3 4	Licensee agreed to relocate R1 to bedroom #1, as required by the approved fire clearance and call fire department under fire clock in case of emergency, by POC due date. Licensee shall submit written confirmation of the relocation and an updated resident room roster to LPA Anguiano at Jose.Anguiano@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:

	Jose Anguiano
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026

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	FACILITY NUMBER: 198320288
	VISIT DATE: 10/09/2026

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Observation and record review revealed that (R1), identified as bedridden in physician’s report, resided in bedroom #4 instead of bedroom #1 as required by the facility’s license and approved fire clearance. Bedroom #1 was occupied by R2, identified as non-ambulatory in physician’s report.

A deficiency was cited under California Code of Regulations, Title 22, Division 6, Chapter 8, on the attached (LIC 809-D). An immediate civil penalty of $500 was assessed on the attached (LIC 421IM).

An exit interview was conducted with Gavina Fuentes, and appeal rights were explained. Copies of this report, LIC 809-D, LIC 421IM, and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026

LIC809 (FAS) - (06/04)

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