<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200549
Report Date: 09/09/2024
Date Signed: 09/09/2024 01:05:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240830154823
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: 6DATE:
09/09/2024
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Nicole Morales, Co AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure facility is free of mal odors
Staff speak inappropriately to resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/9/24 Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a complaint investigation for the above allegation starting at 10:50am. LPA met with Administrator (ADM), Nicole Morals and explain the purpose of the visit.

Allegation: Staff does not ensure facility is free of mal odors: Unsubstantiated

During visit LPA interviewed 4 residents and attempted to interview 2 other residents, and three care staff. LPA took a tour of the facility including but not limited to living room, kitchen, bathroom, and dining area. LPA tour R1, R2, R3, R4, R5, and R6 room. LPA observed all 6 residents’ room do not have an odor smell. LPA observed the facility do not have an odor smell.

Report continued on LIC 9099C...



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20240830154823
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/09/2024
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
26
27
28
29
30
31
32
Allegation: Staff speak inappropriately to resident in care: Unsubstantiated

LPA interviewed 4 out of 6 residents all stated that staff are nice and treat them with respect. When interviewed 4 residents they stated that they have not heard nor witness any staffs yelled or disrespect any residents. LPA interviewed R4 family member that comes daily if R4 family member have heard or witness any staff yelled/speak rudely to any residents R4 family member stated “no, all staff here are nice”. LPA interviewed 3 staff all stated that they do not yell at any residents nor witness any of the staff yelled or being disrespectful to any of the residents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2