<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206952
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:39:36 PM

Document Has Been Signed on 08/10/2022 03:39 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:
08/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Administrator, Marilen GonzalesTIME COMPLETED:
03:49 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/10/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete a case management for a previous visit made on 11/04/21. LPA was COVID pre-screened at time of entry. 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 visit made on 11/04/2022 Licensing Program Analyst M. Garza arrived at the facility and observed two staff (S1 and S2) outside to the right of the facility smoking. Residents were observed to be in the home unsupervised. This poses a potential health and safety or personal rights risk to residents in care. LPA cited Care and Supervision in correlation to complaint #24-AS-20211101082313. A duplicate citation was not given for this today.

On todays visit upon entry, LPA observed the facility front door to be secured with a pin at the bottom of the door. Staff was observed removing the pin and when asked to take a closer look the staff placed the pin in a box. Licensee stated "this was probably old and should not be used anymore". This poses an immediate health and safety or personal rights risk to residents in care. Deficiency cited on the attached LIC809-D

An exit interview was completed. Appeal rights and 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/10/2022 03:39 PM - It Cannot Be Edited


Created By: Mary Garza On 08/10/2022 at 03:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BELLA CARE HOME LLC
FACILITY NUMBER: 107206952

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
CCR
87203

1
2
3
4
5
6
7
87203 Fire Safety -All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
1
2
3
4
5
6
7
Staff immediately removed pin. Licensee to dispose of pin. Hole in door will be patched up by POC date.
8
9
10
11
12
13
14
This requirement was not met as evidence by: LPA observation of front door being secured with a pin at the bottom of the door. This poses an immediate health and safety or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2