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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006382
Report Date: 12/19/2023
Date Signed: 12/19/2023 03:51:11 PM


Document Has Been Signed on 12/19/2023 03:51 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BELLA'S OPEN ARMSFACILITY NUMBER:
306006382
ADMINISTRATOR:YU, TSUNG-SHUNFACILITY TYPE:
740
ADDRESS:1601 SKYLINE DRIVETELEPHONE:
(714) 267-4105
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:6CENSUS: 3DATE:
12/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Tsung-Shun YuTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Tsung-Shun Yu, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 07/12/2023. This is a change of ownership with persons in care.

During the inspection, LPA and AP observed the following: Structure: facility is a 4-bedroom, 3-bathroom, 1-story house with an Accessory Dwelling Unit in the back containing 2 bedrooms and 1 bathroom. Facility telephone number is (714) 213-8423. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lights, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms: the 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Bathrooms: were clean, faucets and toilets were operational. Water temperature: tested at 105.6 degrees F in the common resident bathroom and 105.4 and 106.7 in the private resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the laundry room. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files: LPA reviewed 3 resident files and 2 staff files. Fire clearance was approved by the Fullerton Fire Department on 09/11/2023. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. Facility is currently operating under the liability insurance of current facility CASA DOLCE HOME (306005836). AP will switch liability insurance to new facility once the application is approved.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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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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'S OPEN ARMS
FACILITY NUMBER: 306006382
VISIT DATE: 12/19/2023
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During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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