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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804239
Report Date: 06/05/2024
Date Signed: 06/05/2024 09:11:43 AM

Document Has Been Signed on 06/05/2024 09:11 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:
06/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Assistant Administrator Diandra ChadwickTIME VISIT/
INSPECTION COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Hansen, conducted a pre-licensing inspection, on 6/5/24 at approximately 8:00 AM, and met with Assistant Administrator Diandra Chadwick as applicant Bana Solomon, was unavailable for this mornings visit. Bana Solomon 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.

The last inspection was on 5/23/24 and there were a few items that needed to be completed; The LPA has observed that the following items are complete.

The east & west front door ramp railings have been replaced, and west side ramp walkway has been evened out. Backyard deck has latching fence to keep residents in care from entering back field.

Although east side exit door has not had keycode lock installed that leads out to field. Postings were not posted at todays visit, although LPA observed required postings. Bedrooms 4 & 5 do not have night stands or lights for light stands although rooms do have ceiling lights. Bathrooms do not have paper towels and front yard needs to be cleaned up.

Bana Solomon completed component III orientation on 5/23/24.

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: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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