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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005421
Report Date: 06/14/2024
Date Signed: 06/14/2024 05:04:20 PM

Document Has Been Signed on 06/14/2024 05:04 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BELLA MIA CHATEAU, INC (BMC #1)FACILITY NUMBER:
306005421
ADMINISTRATOR/
DIRECTOR:
VERA, ZENAIDA CFACILITY TYPE:
740
ADDRESS:18410 COLVILLE STREETTELEPHONE:
(714) 227-5766
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 2DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Zeniada Vera, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Zenaida "Zeny" Vera, Administrator.
The facility is a single story building with an approved fire clearance of three non-ambulatory residents of which one may be bedridden and approved for four on hospice. The facility currently has a census of two residents in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 105.6 and 112.7 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on December 27, 2023. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medication appear to be being given as prescribed.

LPA reviewed two of two staff training and fingerprint records.LPA reviewed two of two resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expired on November 13, 2023 and is pending. Proof of documentation supplied and check was cashed.

LPA will return to facility to complete annual at a future date.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiency cited on this date. An exit interview was conducted with Zenaida Vera, Administrator and a copy of the report was given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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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