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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200549
Report Date: 08/19/2024
Date Signed: 08/19/2024 11:58:45 AM

Document Has Been Signed on 08/19/2024 11:58 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AVA BELLA CARE HOMEFACILITY NUMBER:
019200549
ADMINISTRATOR/
DIRECTOR:		JOSEPHINE T. SANTOSFACILITY TYPE:
740
ADDRESS:2483 BALMORAL STREETTELEPHONE:
(510) 324-0444
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
08/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Nicole Morales, Co AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On 8/19/24 at 9:15am LPA K. Nguyen arrived unannounced to conduct a case management in regrades of a resident health and safety by the fire department. LPA spoke with Administrator (AD), Josephine Santos regrading the purpose of the visit. AD was not able to be present due to being out of state. AD asked LPA to discuss the issue with Co-Administrator Nicole Morales who is covering for AD while AD not available.

LPA meet with fire code compliance officer, Joe Villarreal during facility visit. There are recommendation that Joe advice's the facility need to do in order to be compliance with the fire clearance.

Facility needs to complete and turn in by in order for the facility to be compliance with fire code:

-Living room door need to be fix by 8/19/24.

-Fire extinguisher with a current tag by 8/23/24.

-All Room need to be labeling including residents, staff, and bathroom by 8/23/24

- Back gates need to be at least 39 inches wild for wheelchair accessible by 9/9/24

Report continue on LIC 809c...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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: 08/19/2024
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LPA require documents including but not limited to:

-R1 update Physician report by 9/3/24

-R1 update needs and services plan in detail 8/23/24

-Facility needs to show proof AD that R1 can exit the back gate in case of emergency (wheelchair or walker)

-Administrator needs to review reporting requirements in title 22 and submit to CCLD a self certified statement stating that AD understand the regulation by 9/9/24.

Exit interview is conducted and a copy of this report is provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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