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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209190
Report Date: 02/25/2022
Date Signed: 02/25/2022 01:53:26 PM

Document Has Been Signed on 02/25/2022 01:53 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 LLC FARMHOUSEFACILITY NUMBER:
107209190
ADMINISTRATOR:GONZALES, PHILLIPFACILITY TYPE:
740
ADDRESS:1131 FARMHOUSE AVE.TELEPHONE:
(559) 259-6228
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 0DATE:
02/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Phillip GonzalesTIME COMPLETED:
02:26 PM
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Licensing Program Analyst (LPA) Les Xiong conducted an announced Prelicensing visit. LPA met with Licensee and Administrator Phillip Gonzales, and discussed the purpose of the visit.

LPA began the tour at the entrance of the facility and toured the inside and outside of the facility.

Facility was observed at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Common areas furnished and well-lit throughout. Social distancing is maintained. LPA observed the kitchen to be absent of any trash or debris. A two day supply of perishable and seven day supply of non-perishable food were observed.

Medications and chemicals were kept locked in separate cabinets. Residents bedrooms were observed to furnished with bed, dresser, night stand, and overhead lightning. Mattresses, box springs, sheets, and linens, were absent of any tears and stains.

Bathrooms were equipped with non-skid mats and securely fastened grab bars. Towels, linens, and personal hygiene supplies were observed in storage. There are no bodies of water outside.

All Fire extinguishers are current; Carbon monoxide and smoke detectors were observed to be operational. First Aid Kit was checked and observed to have the required supplies. Emergency exit plan, phone numbers, and required postings were observed. A working telephone was present.

Component III was reviewed with Licensee and Administrator. LPA will submit report to Centralized Application Buruea for review and further processing of application.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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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