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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200549
Report Date: 04/27/2022
Date Signed: 04/27/2022 12:13:51 PM

Document Has Been Signed on 04/27/2022 12:13 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AVA BELLA CARE HOMEFACILITY NUMBER:
019200549
ADMINISTRATOR:JOSEPHINE T. SANTOSFACILITY TYPE:
740
ADDRESS:2483 BALMORAL STREETTELEPHONE:
(510) 324-0444
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Gerarda Bajamundi, CaregiverTIME COMPLETED:
12:20 PM
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On 4/27/2022 at 10:15AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Gerarda Bajamundi, Caregiver and explained the purpose of the visit. Administrator, Josephine Santos arrived at 11:00AM.

Upon entry, LPA's temperature was not checked. LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hot water temperature in the shared clients’ bathroom was measured at 107.3 degree Fahrenheit. Fire extinguisher was last serviced on 3/12/2021.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 5/4/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC9099C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AVA BELLA CARE HOME
FACILITY NUMBER: 019200549
VISIT DATE: 04/27/2022
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Continued from LIC9099.

-LIC610E Emergency Disaster Plan
-An updated copy of Administrator certificate

The following deficiencies were observed:

-At 10:35PM, LPA observed resident with full bed rails in bedroom #5.
-At 10:50PM, LPA observed wood, plywood, cardboard boxes, and construction materials in backyard and right side of house.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/27/2022 12:13 PM - It Cannot Be Edited


Created By: Laura Hall On 04/27/2022 at 11:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AVA BELLA CARE HOME
FACILITY NUMBER: 019200549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having full bedrails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
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Administrator agreed to remove bedrails, take photo and submit it to CCLD by POC date.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by having wood, cardboard boxes, exercise bicycle, and construction materials in the backyard and on right side of house poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
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Administrator agreed to have all items removed and submit photo to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
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