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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206952
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:15:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2021 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20211101082313
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:
08/10/2022
UNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Administrator, Marilen GonzalesTIME COMPLETED:
02:38 PM
ALLEGATION(S):
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Resident developed a pressure injury while in care
Staff yelled at resident
Staff did not assist resident with transfers
Staff did not assist resident with toileting needs
INVESTIGATION FINDINGS:
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On 8/10/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced complaint visit to deliver findings. Administrator was contacted and arrived a short time later. Reason for visit was discussed. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms.

During investigation resident files, staff files, hospice records reviewed, and interviews were completed. Review of hospice records showed resident resided at a Skilled Nursing Facility (SNF) and hospital prior to being moved to facility. Records indicated R1 was on hospice at time of move in. Initial intake of resident by hospice showed resident having pressure injuries.

LPA completed interviews with staff and residents. R2 stated, “staff spoke loudly but was never observed to be yelling at residents”. R2 reported “staff assisted R1”, “R1 would be in their motorized wheelchair, outside or in the living room watching TV”.

CONT...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20211101082313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BELLA CARE HOME LLC
FACILITY NUMBER: 107206952
VISIT DATE: 08/10/2022
NARRATIVE
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Staff interviewed reported " R1 was a two person assist and if one staff were busy it could take a little longer to assist R1”. S1 and S2 both indicated R1 was able to state when they needed assistance and was able to toilet themselves once transferred. S1 and S2 stated that all of R2’s care needs were met. This allegations listed above are UNSUBSTANTIATED.

No deficiencies cited during todays visit. Exit interview completed. A copy of this report was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2