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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005830
Report Date: 10/25/2024
Date Signed: 10/25/2024 03:32:14 PM

Document Has Been Signed on 10/25/2024 03:32 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CASA BELLAFACILITY NUMBER:
306005830
ADMINISTRATOR/
DIRECTOR:		SWEENY, ROY P. MDFACILITY TYPE:
740
ADDRESS:2202 E. VALLEY GLEN LANETELEPHONE:
(714) 673-0032
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 4DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Emmanuel Perez
Yeniva Delgado		TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Nancy Guillen made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry by Caregivers Emmanuel Perez and Yeniva Delgado and the nature of the visit was explained.

During the inspection, LPAs and caregivers conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, office, garage and observed the following:

This is a one-story home with six resident bedrooms, one staff bedroom, one staff office, five bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. Fireplace in the living room was observed to be partially screened. The screen does not extend the full length of the fireplace leaving an open gap on one side; a Deficiency was cited on today’s date. LPAs observed all resident beds had linens and blankets. LPAs observed all windows were screened. The backyard has a shaded sitting area. LPAs observed residents watching television and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 107.2- and 116.6-degrees Fahrenheit.

LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Disaster drill log indicated last disaster drill was conducted on June 6, 2023; a Deficiency was cited on today’s date. Fire extinguisher was observed to be fully charged with service tag dated November 17, 2023. An emergency disaster plan was not available for review and staff were unable to provide LPAs with a copy; a Deficiency was cited on today’s date. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Medications, toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. (Cont. LIC809-C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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 10/25/2024 03:32 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 10/25/2024 at 02:18 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CASA BELLA
FACILITY NUMBER: 306005830

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.

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 as the fireplace in the living room was observed to be partially screened. The screen does not extend the full length of the fireplace leaving an open gap on one side which poses a potential safety risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Staff Delgado stated the fireplace screen would be replaced to ensure screen covers the fireplace entirely and provide LPA with picture proof via email by POC date.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as an emergency disaster plan was not available for review and staff were unable to provide LPAs with a copy which poses a potential health, safety an personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Staff Delgado stated an emergency disaster plan will be completed and a copy provided to LPA via email by POC date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2024 03:32 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 10/25/2024 at 02:18 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CASA BELLA
FACILITY NUMBER: 306005830

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the disaster drill log indicated last disaster drill was conducted on June 6, 2023 which poses a safety risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Staff Delgado stated emergency disaster drill will be conducted and documented quarterly and a copy provided to LPA via email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CASA BELLA
FACILITY NUMBER: 306005830
VISIT DATE: 10/25/2024
NARRATIVE
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LPAs reviewed four resident files and two staff files which met all the requirements. LPAs interviewed three residents and two staff.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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