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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005239
Report Date: 10/27/2023
Date Signed: 10/27/2023 11:24:03 AM

Document Has Been Signed on 10/27/2023 11:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BELLA CLARE HOMEFACILITY NUMBER:
306005239
ADMINISTRATOR:JOSHUA ESTREVILLOFACILITY TYPE:
735
ADDRESS:8411 SAN CARLOS WAYTELEPHONE:
(562) 728-7577
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 2DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Joshua Estrevillo - AdministratorTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into facility by DSP Elmer Catungal. LPA began the tour but at 9:45 was asked to leave the facility briefly as the staff present had to accompany the present resident to a doctor’s appointment. LPA returned to the facility at 10:15am after Administrator Joshua Estrevillo returned.

The facility is a one-story home with four client bedrooms, two bathrooms, kitchen, dining room, living room, laundry room, an office, backyard, front patio and garage. Staff stated residents were away at day program and a medical appointment. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. LPA observed keypads on client bedroom doorknobs. AD stated the keypads were installed due to a client who would enter other client bedrooms without permission. AD consulted with families of clients before installing doorknobs. AD stated the client who would enter rooms without permission was evicted in September 2023. AD stated they will be changing doorknobs to a fingerprint system that clients are able to use on their own as opposed to the keypads. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 107.2 degrees Fahrenheit in the bathroom accessible from the living room and 113.7 degrees Fahrenheit in the bathroom accessible from the hallway. LPA observed facility has emergency food and water supply. Medication for each resident is kept in locked cabinets in the kitchen. The front and back yards both have a shaded seating area. The two exit gates are unlocked and self latching. LPA reviewed both of the resident files and medication. Residents were not present for interview. LPA observed fire extinguisher to be fully charged. Service tag indicated that the extinguisher was serviced on 6/14/23. Facility has admitted a third resident who is doing multiple visits each week leading up to their actual move-in date to prime the soon-to-be resident and get them acclimated to the facility ahead of their move-in date.

No deficiencies noted during today's visit. An exit interview was conducted with AD Joshua Estrevillo and a copy of this report was provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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