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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200549
Report Date: 12/11/2024
Date Signed: 12/11/2024 04:48:02 PM

Document Has Been Signed on 12/11/2024 04:48 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:
NICOLE MORALESFACILITY TYPE:
740
ADDRESS:2483 BALMORAL STREETTELEPHONE:
(510) 324-0444
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Armand Devera, Care StaffTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On this day at around 1:30 pm, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection upon arrival LPA was greeted by care staff, Armand Devera. LPA spoke with Administrator Josephine Santos (Administrator certificate #6063810740 exp 6/23/26). Josephine was not available during inspection LPA explained to Josephine the purpose of the visit. Josephine gave verbal permission for care staff Armand to sign the report.

During the visit, LPA inspected the facility inside and out including but not limited to resident bedrooms, bathrooms, kitchen, dining area, garage and backyard. There was sufficient supply of perishable and non perishable foods. The facility room temperature was observed set at 72 Fahrenheit. There was sufficient supply of linen, warm blankets, sheets and towels available for use of the residents. A fire extinguisher that appeared full and was last serviced on 8/21/2024 was observed. The facility has a first aid kit that appeared complete. The last fire drill was conducted on 10/30/2024.

Due to insufficient time LPA will continue this annual inspection at a later time.

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: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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