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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005421
Report Date: 06/04/2025
Date Signed: 06/04/2025 12:47:10 PM

Document Has Been Signed on 06/04/2025 12:47 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: 1DATE:
06/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator - Zenaida VeraTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On June 4, 2025 at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by the Caregiver (CG) Ramon Vera, and explained the reason for the visit. Administrator Zenaida Vera joined shortly after and was present throughout the visit. AD Zenaida Vera has an Administrator certificate that expires on November 13, 2025.

The facility is a single story building with an approved fire clearance of three non-ambulatory residents of which one may be bedridden and three approved for hospice. The facility currently has a census of one resident in care, on which one is on hospice.

At 9:00 AM, LPA Bentley toured the facility with CG Vera. The home consists of 4 resident bedrooms,1 staff bedroom, 3 full bathrooms, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperatures measured between 108.3 degrees F. and 117.9 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards and doorways were free of obstructions. Kitchen was inspected and found clean and sanitary. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps and toxin substances to be secured and locked and inaccessible to residents. Kitchen appliances are operational during today's visit.

CONTINUE TO LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/04/2025 12:47 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/04/2025 at 11:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BELLA MIA CHATEAU, INC (BMC #1)
FACILITY NUMBER: 306005421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above, which poses an immediate safety risk to persons in care. LPA observed records of last fire, emergency, and disaster drill conducted on June 15, 2024. No drills have been conducted since that date.
POC Due Date: 06/05/2025
Plan of Correction
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Licensee stated they will conduct drill today and email LPA the content covered in the training, training attendees and the date and time of training to CCLD by POC due date.
Type A
Section Cited
CCR
87465(h)(6)(A-F)
Incidental Medical and Dental Care Services. Licensee shall be responsible for assuring that a record of centrally stored
prescription medications for each resident is maintained for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of the centrally stored medication form & MAR, the licensee did not comply with the section cited above in
three out of three resident records, which poses an immediate health and safety risk to persons in care. LPA observed resident medication and records and found licensee has not updated documents for R1's, R2's, and R3's medication on entrally stored medication form & MAR since December 2024.
POC Due Date: 06/05/2025
Plan of Correction
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Licensee will ensure all residents medication is documented on MAR and centrally stored medications form and sign off on each medication administered, effective immediately. Licensee stated they will review regulations and re-train the facility staff on how to accurately record resident medications. Licensee stated they will email LPA the content covered in the training, training attendees and the date and time of training and send to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BELLA MIA CHATEAU, INC (BMC #1)
FACILITY NUMBER: 306005421
VISIT DATE: 06/04/2025
NARRATIVE
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LPA toured the outside grounds and there is ample seating with shade. The exit gate is self latching and operational. The backyard has a small garden area.

LPA observed carbon monoxide and smoke detectors in common areas and bedrooms operational. The facility’s last fire drill was conducted on June 15, 2024 and a deficiency is being cited. Emergency food and water supply was observed in the garage. First aid kit had all the required elements. A fire extinguishers is fully charged with a service date of December 9, 2024. A working telephone (714-227-5766) remains available, and the facility has a device that can be used for video teleconference purposes.

LPA Bentley conducted an audit of three (3) resident files (R1-R3), two (2) staff files (S1-S2), and conducted two (2) staff interviews, and one (1) resident interview. Residents’ medication was found locked and secure and a review of the Medication and Medication Administration Record (MAR) was conducted. LPA observed three out of three residents, Residents #1, Resident #2, and Resident #3 with medication not listed on MAR and centrally stored medication form since December 2024. A deficiency is being cited.

Based on today’s observations, deficiencies are being cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted with administrator, Zenaida Vera and a copy of this report LIC809, LIC809-C, LIC809-D, and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
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