306005239-9-20-2022-22-AS-CDPO-CJFTBG-20220920143506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005239
Report Date: 09/20/2022
Date Signed: 09/20/2022 02:35:16 PM

Document Has Been Signed on 09/20/2022 02:35 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BELLA CLARE HOME		FACILITY NUMBER:	306005239
ADMINISTRATOR:	JOSHUA ESTREVILLO		FACILITY TYPE:	735
ADDRESS:	8411 SAN CARLOS WAY		TELEPHONE:	(562) 728-7577
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 4		CENSUS: 0	DATE:	09/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Facility Administrators - Joshua Estrevillo, Trish Estrevillo		TIME COMPLETED:	02:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio arrived to facility at 12:50 PM, and contacted facility administrator (AD) Joshua Estrevillo about visit due to observing no one present at facility and no response received upon ringing the doorbell at facility entrance. Both facility administrators Joshua Estrevillo and Trish Estrevillo arrived at facility at 1:15 PM. During the visit, LPA De Perio observed and verified that there were no staff and no clients present at facility. The PUB475 "See Something, Say Something" poster was observed in the staff office and in each bedroom. LPA De Perio observed the Administrator's Certificate for Joshua Estrevillo, which expires on 10/1/22 and Trish Estrevillo which expires on 10/1/22. LPA De Perio toured the interior and exterior portions of the facility with ADs Estrevillo. The facility is a single level structure and is licensed for four adult clients, of which 2 may be non-ambulatory. Currently, there are a total of 0 clients in care. There are a total of 4 single bedrooms. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. LPA De Perio toured each room and verified that there are no clients currently living at the facility, and observed no client belongings present. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilets were operational. Water temperature in restrooms were measured to be at 105.2 degrees Fahrenheit.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BELLA CLARE HOME	FACILITY NUMBER: 306005239
	VISIT DATE: 09/20/2022

NARRATIVE

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Facility met the minimum seven-day non-perishable food supplies, however did not have two-day perishable food due to no clients and staff present. LPA De Perio observed the designated locked location for sharp items and knives, however LPA De Perio verified that there were no sharps, and knives present at facility. Fire extinguisher was observed in the garage, however, per ADs Estervillo, once renovations are completed, fire extinguisher will be mounted, and located in the kitchen. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components.

The facility had an adequate supply of PPE that was located in the staff office and garage. LPA De Perio observed the designated spot for medications, of which it is made inaccessible to clients in care. However, LPA De Perio verified that there were no medications present due to no clients residing at facility. Toxins and disinfectants were also observed to be locked located in the laundry room.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are two gates in the backyard, which both were self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with ADs Estrevillo. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BELLA CLARE HOME	FACILITY NUMBER: 306005239
	VISIT DATE: 09/20/2022

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NOTE: Facility has been vacant since 3/14/22 as verified by ADs Estrevillo due to paintings and renovations being conducted.

Per interview conducted with ADs Estrevillo, it was stated that LPA Jerome Haley and Orange County Adult and Senior Care Regional Office have been notified that clients previously residing in Bella Clare Home have been relocated to Bella Clare Home 2 as of 3/14/22.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised ADs Estrevillo to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with ADs Estrevillo and a copy of this report was provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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