335530124-8-25-2023-56-AS-RGAR-CV2NT3-20230825104405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530124
Report Date: 08/25/2023
Date Signed: 08/25/2023 10:44:15 AM

Document Has Been Signed on 08/25/2023 10:44 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BELLA CAI CARE HOME		FACILITY NUMBER:	335530124
ADMINISTRATOR:	ABDULLAH, SITI KHATIJAH		FACILITY TYPE:	740
ADDRESS:	29111 OAK GROVE WAY		TELEPHONE:	(562) 537-8885
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	6	CENSUS: 0	DATE:	08/25/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Sitikhatij Abdullah- Administrator		TIME COMPLETED:	10:53 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ryan Gardner conducted an announced visit to complete the Pre-licensing inspection. LPA met with Administrator Sitikhatij Abdullah for a Residential Care Facility for six (6) ambulatory residents. The fire clearance was approved by the fire department on 6/28/2023. The facility has five (5) bedrooms and three (3) bathrooms. There are three (3) resident bedrooms, two (2) staff bedrooms, a kitchen/dining area, one (1) main living room area, a laundry room, a backyard, and an attached garage. LPA toured the interior and exterior areas of the facility. The following were inspected: Resident Bedrooms: All bedrooms have the required bedding and furniture, such as clean mattresses/linen, nightstands, dressers, chairs, and lighting. Resident Bathrooms: The bathrooms appliances were operating in safe and sanitary condition. The water temperature was measured by LPA, the thermometer read at 107.6 degrees F. Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for resident use. Kitchen appliances and countertops were free of debris and in good repair. The refrigerator was measured at 40 degrees F and the freezer was measured at 0 degrees F. The facility has a posted meal schedule. Sharps/Medication: The knives, sharps, and location for medications were safely locked and secured. Common Sitting Areas/Activities: There is adequate seating in the common areas for the residents. The facility has a supply of activities for the residents. The facility has posted an activity schedule. Laundry: The chemicals and laundry soap were safely locked in the laundry room.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BELLA CAI CARE HOME	FACILITY NUMBER: 335530124
	VISIT DATE: 08/25/2023

NARRATIVE

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Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies were available for each resident.

Backyard: There are no bodies of water in the backyard. There is a covered area with seating for the all the residents. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There is one (1) charged fire extinguisher in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and or ammunition.

Postings: LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, labor laws, and personal rights.

First aid and working telephone: The facility is equipped with a complete first aid kit and manual. The facility has a working telephone for resident use.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA has determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and the facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

The required Comp III presentation was completed. An exit interview was conducted, and this report was discussed and provided to Administrator Sitikhatij Abdullah.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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