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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005830
Report Date: 10/06/2021
Date Signed: 10/06/2021 12:27:29 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 BELLAFACILITY NUMBER:
306005830
ADMINISTRATOR:SWEENY, ROY P. MDFACILITY TYPE:
740
ADDRESS:2202 E. VALLEY GLEN LANETELEPHONE:
(714) 673-0032
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 4DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Roy P. Sweeny MD, AdministratorTIME COMPLETED:
12:36 PM
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Licensing Program Analysts (LPAs) Ruth Martinez and Beverly Thompson-Gracia conducted an unannounced visit for the purpose of conducting a required inspection visit. LPAs were greeted at the door by caregiver and granted entry. LPA advised caregiver the nature of the visit. Administrator arrived shortly after.

LPAs began the tour of the inside and outside of the facility. The facility currently has four residents in care and no active covid-19 cases. LPA observed residents in living room and outdoor seating area. All residents appeared happy and well take care of. Facility appears clean and sanitary. Facility screens all visitors to the facility and LPAs observed the screening station in the entrance of the facility. Facility keeps documentation in regard to covid for all the staff and residents. The hot water temperature was measured at 118.4 Fahrenheit degrees. LPAs observed all required department posting throughout the facility. Facility has an active covid-19 prevention plan in place for the safety or residents in care. LPAs observed the emergency food and water as well as first aid kits in the facility. Facility has supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place throughout the facility and in all common spaces. LPAs toured the outside and observed several shaded outside space for residents enjoyment. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility has completed the LIC808 Mitigation plan and it was approved by the Department on June 09, 2021.

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.

An exit interview was conducted, this report was reviewed with Administrator and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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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