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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005421
Report Date: 06/18/2024
Date Signed: 06/18/2024 02:55:46 PM

Document Has Been Signed on 06/18/2024 02:55 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:
06/18/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Zenaida Vera, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to complete the Annual Required Evaluation from Friday, June 14, 2024. LPA was greeted and granted entry by Zenaida 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 four approved for hospice. The facility currently has a census of two residents in care in which one is on hospice.

During today’s visit, LPA continued to review staff and resident files. The last fire drill was conducted on June 15, 2024. LPA confirmed one employee is almost done with training requirements and the administrator's certificate and training are current.

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 deficiencies were cited but one technical violation was given.

An exit interview was conducted with Zenaida Vera, Administrator and a copy of the report, LIC 9102TV and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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