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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206952
Report Date: 04/27/2024
Date Signed: 04/27/2024 12:45:20 PM

Document Has Been Signed on 04/27/2024 12:45 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/
DIRECTOR:		GONZALES, MARILENFACILITY TYPE:
740
ADDRESS:508 GATEWAY AVETELEPHONE:
(559) 259-6228
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 6DATE:
04/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator Marilen GonzalesTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by Staff Ann Lorio and explained the purpose of the visit. Licensee/Administrator Marilen Gonzales responded to the facility to assist with the visit.

The residence was set at 73 degrees F temperature and free of passageway obstructions inside and outside. LPAs observed five bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition. Hot water temperature was measured at 118 degrees F. Residents were eating their breakfast when LPA arrived.

Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. Medication and knives are locked in a kitchen cabinet. Cleaning supplies were locked in the hallway closet. Smoke and carbon monoxide are dual detectors, they were checked and operating. Fire extinguishers was service on 2/5/2024. Last drill completed on 02/05/24.

There was outdoor seating for the residents. Outdoor area was clean and free of obstruction. Facility has a pool which is gated, locked and inaccessible to residents in care.

Resident and staff records were reviewed. Medications were reviewed. Facility does not have any residents on Hospice or Home Health. Staff have CPR/First Aid training. Staff had partial training for dementia.

An exit interview was conducted with Administrator, and a copy of this report along with appeal rights was provided.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2024
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 5
Document Has Been Signed on 04/27/2024 12:45 PM - It Cannot Be Edited


Created By: Shawna Doucette On 04/27/2024 at 10:53 AM
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: 04/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in Licensee did not have complete training for staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Licensee agrees to complete staff training for all staff and will submit where the staff obtained the training, hours of training to meet regulation and certificates of staff that completed the training by POC due date 5/24/24.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2024


LIC809 (FAS) - (06/04)
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