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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530124
Report Date: 07/27/2023
Date Signed: 07/27/2023 04:12:28 PM


Document Has Been Signed on 07/27/2023 04:12 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:BELLA CAI CARE HOMEFACILITY NUMBER:
335530124
ADMINISTRATOR:MAGSAYSAY, CHARISSEFACILITY TYPE:
740
ADDRESS:29111 OAK GROVE WAYTELEPHONE:
(562) 537-8885
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:6CENSUS: 0DATE:
07/27/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Siti Abdullah & Charisse MagsaysayTIME COMPLETED:
01:52 PM
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Component II completion: Successful

Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Siti Abdullah (Administrator) & Charisse Magsaysay (Licensee)
Interview Method: Virtual interview via Microsoft Teams


On July 27, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Diamond LawTELEPHONE: (916) 657-3571
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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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