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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206952
Report Date: 04/25/2022
Date Signed: 04/28/2022 03:50:33 PM

Document Has Been Signed on 04/28/2022 03:50 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BELLA CARE HOME LLCFACILITY NUMBER:
107206952
ADMINISTRATOR:GONZALES, MARILENFACILITY TYPE:
740
ADDRESS:508 GATEWAY AVETELEPHONE:
(559) 259-6228
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 6DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Administrator, Marilen GonzalesTIME COMPLETED:
03:00 PM
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On 04/25/2022 Licensing Program Analyst, M. Garza arrived at the facility unannounced to conduct the required Infection Control Inspection. Administrator was contacted and arrived a short time later. LPA was greeted by Direct Care Staff, Johanna Lorio and COVID pre-screened. LPA was permitted entry into the facility. LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. Resident observed in rooms and common areas.

Mitigation plan was received and reviewed. COVID-19 procedures described in the plan include required postings, symptoms screenings (for staff, persons in care and visitors), testing, quarantine/isolation cohorts, infection control plan to include donning and doffing of Personal Protective Equipment. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed. 1 of 2 staff observed wearing face coverings. Facility has designated visitation areas. Covered trash bins were observed. LPA observed residents with a 30-day supply of resident medications. A 30 day supply of PPE not observed. Licensee has available at different location. Licensee to provided additional PPE. Sinks are well stocked and liquid soap for hand washing and paper towels for hand drying were observed.

Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices are found to be in compliance. Exit interview conducted.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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