306005830-6-2-2021-22-AS-RMAZ-C3LS7X-20210602133815

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005830
Report Date: 06/02/2021
Date Signed: 06/02/2021 01:38:19 PM

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:	CASA BELLA		FACILITY NUMBER:	306005830
ADMINISTRATOR:	SWEENY, ROY P. MD		FACILITY TYPE:	740
ADDRESS:	2202 E. VALLEY GLEN LANE		TELEPHONE:	(714) 673-0032
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 3	DATE:	06/02/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:56 AM
MET WITH:	Roy P. Sweeny MD, Administrator		TIME COMPLETED:	01:55 PM

NARRATIVE

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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to Community Care Licensing. LPA arrived at facility was greeted at the door by caregiver and granted entry. LPA explained the nature of today’s visit and caregiver advised AD of visit. Administrator Roy P. Sweeny MD arrived shortly after and met with LPA. Incident was self reported on April 14, 2021 regarding R1’s incident on April 13, 2021.

LPA spoke to Administrator on May 17, 2021 about details of incident in question. Today’s visit is as a follow up from conversation held on that date. During today’s visit, LPA took a tour of the facility, interviewed staff and obtained copies of pertinent documents.

On April 13, 2021 R1 in conversation with transportation driver said R1 was having a relationship with a male caregiver. Based on interviews and information obtained while in review of records. Facility has always had a policy since R1 moved into facility that no male caregiver was to assist at any time. As this was the request by R1 as a preference. Facility has accommodated to request and was also informed by family that R1 has had previous behavior episode from at other board and care facilities. Responsible party agreed with R1’s request and as a precautionary measure for R1’s care. As an additional precautionary measure since incident Administrator has made sure that any reliever caregiver is a female to make sure accommodations are met.

Upon review of records, interviews and facility tour, everything is within regulations and no concerns are noted. Facility addressed incident and address any concerns in regard to incident. LPA did not observe any immediate and/or safety risks in or out of the facility.

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

This report was reviewed with facility representative and a copy of the LIC809 and LIC811 was provided and left at the facility.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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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