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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200549
Report Date: 12/12/2024
Date Signed: 12/12/2024 10:39:34 AM

Document Has Been Signed on 12/12/2024 10:39 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:		NICOLE MORALESFACILITY TYPE:
740
ADDRESS:2483 BALMORAL STREETTELEPHONE:
(510) 324-0444
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
12/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Josephine Santo, AdminstratorTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
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On 12/12/24 at 8:50AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an continuation of an annual required inspection upon arrival LPA met with Administrator Josephine Santos (Administrator certificate #6063810740 exp 6/23/26), and explained the purpose of the visit.

LPA reviewed 5 resident files and 3 staff files. LPA interviewed 2 residents and 2 staff.

The following deficiencies were observed:
· medicine unlocked inside the small cabinet on the table- Cleared but Repeated Violation from 1/27/24.
· Cleaning supplies/ detergent left unlocked under shared resident bathroom and common bathroom- Cleared.
· Knives left unlocked in on the kitchen counter- Cleared.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month. *

Exit interview conducted. A copy of the LIC421FC, this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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Document Has Been Signed on 12/12/2024 10:39 AM - It Cannot Be Edited


Created By: Kelly Nguyen On 12/12/2024 at 10:06 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: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 by having knife left unlocked on the kitchen counter which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Staff locked knife during inspection. Defiency cleared
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 by having •medicine unlocked inside the small cabinet on the table, and detergent left unlocked under shared resident bathroom and common bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Staff locked medication during inspection. Defiency cleared
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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