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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006068
Report Date: 06/28/2023
Date Signed: 06/28/2023 05:27:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2023 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230628094002
FACILITY NAME:BELLA CLARE HOME 2FACILITY NUMBER:
306006068
ADMINISTRATOR:JOSHUA ESTREVILLOFACILITY TYPE:
735
ADDRESS:6892 SAN PADRE CIR.TELEPHONE:
(714) 723-6780
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:4CENSUS: 2DATE:
06/28/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Joshua Estrevillo - AdministratorTIME COMPLETED:
12:59 PM
ALLEGATION(S):
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Staff verbally abused and intimidated client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit in regards to the complaint allegation above. Upon arrival staff called Administrator (AD) Joshua Estrevillo via telephone who arrived a short time later and was present for the visit. LPA Haley discussed the reason for the visit with AD Estrevillo.

During the visit, LPA Haley interviewed AD Estrevillo, Staff 1(S1), and attempted interviews with client 1 (C1), and client 2 (C2) regarding the complaint allegation. During the investigation, interviews confirmed S1 was heard on the audio recording provided to the department.

Based on the evidence gathered through interviews and review of the audio provided, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.
An exit interview was conducted and a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20230628094002
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BELLA CLARE HOME 2
FACILITY NUMBER: 306006068
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2023
Section Cited
CCR
80072(a)(3)
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(a) Except it children's residential facilities, each client shall have personal rights... not limited to the following:
(3) To be free from... unusual punishment, infliction of pain, humiliation, intimidation, ridicule... or other actions of a punitive nature... or aids to physical functioning.
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Administrator Estrevillo will review regulation section 80072 (Personal Rights) and 80064 (Administrator Qualifications & Duties) and provide LPA a signed documented acknowledging this was completed. Provide a detailed description on how this violation will be prevented from happening in the future. Schedule an in-service training (related topic)for all staff and provide a signed attendance sheet for all in attendance.
This is due by 12:00 Noon, July 5, 2023.
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This requirement is not being met as evidenced by the audio recording that was provided to the department, and interview confirmation. This poses a potential healthy and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
LIC9099 (FAS) - (06/04)
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