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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200549
Report Date: 09/09/2024
Date Signed: 09/09/2024 01:22:51 PM

Document Has Been Signed on 09/09/2024 01:22 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/
DIRECTOR:		JOSEPHINE T. SANTOSFACILITY TYPE:
740
ADDRESS:2483 BALMORAL STREETTELEPHONE:
(510) 324-0444
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
09/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Nicole Morales, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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
LPA conducted an unannounced case management regrading the the update physician report for R1. LPA meet with Administrator (ADM), Nicole Morales and explained the purpose of the visit.

ADM explained to LPA there are some complication of R1 primary doctor, which R1 case manger is aware and is trying to schedule for R1 to see another doctor. ADM will notify LPA sometime next week of the process of getting R1 physician report.

LPA explained to ADM when calling 911 for R1 regrading R1 condition. When calling 911 for R1 all staff must know the term (bariatric) in order for the emergency crew to be prepared. ADM agreed and understood.

ADM confirmed with Joe fire department of the POC of the back gate from 9/9/24 to 9/18/24.

No deficiency issue on today date.

Exit interview is conducted a report is provided.
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.

LIC809 (FAS) - (06/04)
Page: 1 of 1