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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604790
Report Date: 05/02/2024
Date Signed: 05/02/2024 04:46:17 PM

Document Has Been Signed on 05/02/2024 04:46 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BELLAHOMECARE IFACILITY NUMBER:
374604790
ADMINISTRATOR/
DIRECTOR:		COOK, CHERRYFACILITY TYPE:
740
ADDRESS:629 GUAVA AVETELEPHONE:
(406) 998-8022
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 6CENSUS: 4DATE:
05/02/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Administrator Cherry CookTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit to check on residents. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Cherry Cook.

LPA toured the facility, performed a health and safety welfare check on residents in care, and interviewed staff. No deficiencies were observed or cited on this date.

An exit interview was conducted with Cook, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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