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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005239
Report Date: 10/09/2024
Date Signed: 10/09/2024 11:39:58 AM

Document Has Been Signed on 10/09/2024 11:39 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BELLA CLARE HOMEFACILITY NUMBER:
306005239
ADMINISTRATOR/
DIRECTOR:		JOSHUA ESTREVILLOFACILITY TYPE:
735
ADDRESS:8411 SAN CARLOS WAYTELEPHONE:
(562) 728-7577
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 3DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:04 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 10/09/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Assistant Administrator Lorna Cruz was present to assist with the facility inspection on today's date.
Facility is licensed as a Adult Residential Facility capacity 4 with approved Non Ambulatory for 2 clients. Currently, there are three clients (3) present during today’s visit. Facility is a Level 4I home.

This is a single story with a two-car garage facility. The facility has five bedrooms ( 4 client bedrooms, 1 staff room), 1 office room and two full bathrooms.

At around 7:21AM, LPA conducted a tour of the physical plant accompanied by caregiver and Assistant Administrator, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 111.9 degrees F. A comfortable temperature of 72 degrees F. was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. LPA observed storage areas for personal hygiene. LPA observed sharps objects were locked and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has a emergency food and water supply. LPA observed two fire extinguishers were charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BELLA CLARE HOME
FACILITY NUMBER: 306005239
VISIT DATE: 10/09/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols and sanitizing stations in common areas and restrooms. LPA observed the facility has supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. The last fire drill was conducted on 9/10/2024 and smoke detectors were tested in rooms and common areas. The facility has current liability insurance on file effective 3/4/2024 - 3/4/2025. Facility has Surety Bond on file effective 8/14/2022-8/14/2026

A review of three clients (C1-C3) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Ma Lorna Cruz # 6069284735 - Expiration 04/08/2026

No deficiencies during this inspection visit.

An exit interview was conducted with Assistant Administrator and a copy of the report was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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