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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804239
Report Date: 05/23/2024
Date Signed: 05/23/2024 11:41:57 AM

Document Has Been Signed on 05/23/2024 11:41 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BLUEBELL MANORFACILITY NUMBER:
496804239
ADMINISTRATOR/
DIRECTOR:		SOLOMON BANAFACILITY TYPE:
740
ADDRESS:1997 BLUEBELL DRIVETELEPHONE:
(707) 800-2522
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 0DATE:
05/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator/Licensee Bana SolomonTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Shannan Hansen, conducted a pre-licensing inspection,on 5/23/24 at approximately 8:30AM, and met with applicant Bana Solomon, who will also be the facility's Administrator. RCFE Administrator Certificate #6063962740 expires 8/12/2024.

Facility is fire cleared for six(6) non-ambulatory, which includes one(1) bedridden, effective 3/19/24. Applicant has an approved dementia plan of operation. Applicant has submitted an infection control plan for the home as required.

Facility is one story with 7 bedrooms, 3 bathrooms, staff breakroom in garage, kitchen/dining room, living room, and a backyard deck. There are two fire extinguishers, inspected and tagged as required 4/9/24. Facilities eleven (11) smoke alarms were working appropriately during the inspection, some are duel carbon monoxide detectors. All exits were unobstructed during the inspection. All exit doors had auditory alarms for use once the home is operating; All exit auditory alarms were working appropriately during the inspection. Backyard gate is self latching and opened appropriately. There are ramps on both sides of the front of the home leading up to the front door for use as needed.

All bathrooms had grab bars as required, and non-slip flooring in showers for resident use. The hallways had night lights for resident use. The facility had appropriate furnishings for resident use. Facility has all necessary and required utilities on and operating appropriately. All kitchen appliances were working appropriately. The kitchen has the stove/range knobs covered so they are inaccessible to future residents in care. There is a locking cabinet in the kitchen to store the knives and other sharps. The kitchen also has a cabinet under the sink that can be locked for toxins/cleaners to ensure they are inaccessible to future residents in care. Other cleaners/toxins will be stored in the garage and inaccessible to residents in care. Hot water was checked at 115, 118.4 & 120.5 degrees F.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BLUEBELL MANOR
FACILITY NUMBER: 496804239
VISIT DATE: 05/23/2024
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Administrator informed there is 2 water heaters and has turned one down. There is a key code lock and key access to a small storage closet in the hallway that will be used to secure medications and keep them locked and inaccessible to future residents. There is also a key code lock and key access to Kitchen door to garage containing laundry room, office where records will be kept and with other supplies such as cleaners/toxins, inaccessible to residents in care.

Applicant completed Component III Orientation during the pre-licensing inspection.



Applicant's front door ramps needs the wood railings to be replaced due to unstable/shaky & west side ramp has uneven pavement Administrator tripped over during inspection that will need to be fixed; Applicant has an appointment set up for this to be done. Backyard deck to have latching fence to keep residents in care from entering back field with holes, etc.. East side exit door to have key code lock to prevent residents from exiting as there is a cement step outside of door that residents could fall off of. Applicant will finish putting things together and up as discussed such as Posting of all required documents.

The applicant will contact LPA Hansen when the items listed above are complete;
LPA will schedule another pre-licensing continued inspection to reinspect as needed.
The applicant may contact the LPA at the contact number provided if there are any questions to the above information.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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