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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006068
Report Date: 11/29/2022
Date Signed: 11/29/2022 10:17:34 AM

Document Has Been Signed on 11/29/2022 10:17 AM - It Cannot Be Edited

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: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:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Joshua EstrevilloTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff called the Administrator (AD) Joshua Estrevillo upon LPAs arrival.

At 8:30 AM LPA Haley began the tour of the facility with staff. LPA Haley observed a screening station right next to the front door with hand sanitizer, face mask, gowns, gloves, and a temperature thermometer mounted on the wall. In the cabinets below the screening station, LPA Haley observed emergency bags for the clients.

There were two clients present for the visit. All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp, plenty of clean linen and storage space. All client bathrooms were clean and well organized. Hot water temperature was measured at 114 degrees Fahrenheit in client bathroom #1(Rm 5), 111.9 degrees Fahrenheit in client bathroom #2 (Hallway),113.5 degrees Fahrenheit in client bathroom #3, and 111.7 degrees Fahrenheit in client bathroom #4.

The kitchen was clean and organized. All knives and sharp objects were locked in cabinet next to the stove. All burners on the stove were operational. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items that were labeled and neatly organized in the kitchen cabinets.

The living room was clean and organized. LPA Haley observed activities for the clients, ipads the clients use, and a karaoke station for the clients to enjoy. Next to the dining room is a locked staff office. In the staff office, LPA observed a computer, printer, a locked bathroom, a locked medication closet, and two locked file cabinets used to store client and staff files. In the staff office was a first aid kit with all the required elements.

During the inspection, LPA Haley observed two fully charged and mounted fire extinguishers. One right outside bedroom #5 and the second extinguisher was mounted on the wall between the dinning room and kitchen.


Continued on LIC809C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 11/29/2022
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In the garage, LPA observed an emergency supply of PPE: mask, gowns, gloves, hand sanitizer kept neatly organized in the cabinets. Two emergency food buckets, and an additional emergency bag was observed. There is a large emergency kit with four bags of various emergency supplies (food, water first aid, etc.) prepared and ready to go. LPA observed plenty of clean linen in the cabinets. A washer and dryer, and a well stocked supply of hygiene items was observed in the garage. LPA Haley also observed gym equipment that will be used to set up a small gym for the clients to enjoy.

The backyard was clean, organized, and free of clutter. Side exit gate were self closing and self latching. Two shaded areas with chairs and plenty of seating was observed. Further, LPA observed a basketball court and basketballs, skate boards, bikes, and an oversized connect 4 game in the backyard.

No bodies of water observed. All smoke detectors were tested and are operational. No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC809 (FAS) - (06/04)
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