306005421-5-10-2022-22-AS-RQUZ-CEAUFX-20220510153329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005421
Report Date: 05/10/2022
Date Signed: 05/10/2022 03:33:34 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/10/2022 03:33 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 MIA CHATEAU, INC (BMC #1)		FACILITY NUMBER:	306005421
ADMINISTRATOR:	VERA, ZENAIDA C		FACILITY TYPE:	740
ADDRESS:	18410 COLVILLE STREET		TELEPHONE:	(714) 227-5766
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 3	DATE:	05/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:42 PM
MET WITH:	Ramon Vera, Caregiver		TIME COMPLETED:	03:37 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	On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Caregiver (CG) Ramon Vera. LPA Rosie Quiroz explained the nature of the visit to (CG) Ramon Vera. Licensee/Administrator Zenaida Vera not able to be present during today's visit due to a pre-scheduled appointment. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to Age range 60 and over, 3 Non Ambulatory, of which 1 may be bedridden and has a Hospice Waiver for 4 residents. Facility currently providing services to two residents on hospice. Administrator Zenaida Vera has a current Administrator certificate with expiration date of November 13, 2023. On or about 1:55pm, LPA Rosie Quiroz along with (CG) Ramon Vera began the tour of the inside and outside of the facility. There are three residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed one of three residents in living room area resting and watching television, and two of three residents in their bedroom relaxing watching television. LPA Quiroz interacted and interviewed with resident's during today's visit. Three of three residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within 108-120 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area for resident and visitor's enjoyment in backyard area. The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on June 7, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated June 7, 2021. Continued on next page...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

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 MIA CHATEAU, INC (BMC #1)	FACILITY NUMBER: 306005421
	VISIT DATE: 05/10/2022

NARRATIVE

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LPA Quiroz was informed that all residents and staff have had their COVID-19 vaccinations and Boosters and will be scheduling second booster this month after speaking to resident's families. Facility indicated to be recording resident's temperatures three per day.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit.

This report was reviewed with (CG) Ramon Vera, and a copy of this report and LIC 811 Confidential Names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC809 (FAS) - (06/04)

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