496804239-4-15-2025-21-AS-DALO-DFRTH3-20250415144404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804239
Report Date: 04/15/2025
Date Signed: 04/15/2025 02:44:13 PM

Document Has Been Signed on 04/15/2025 02:44 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BLUEBELL MANOR		FACILITY NUMBER:	496804239
ADMINISTRATOR/ DIRECTOR:	SOLOMON BANA		FACILITY TYPE:	740
ADDRESS:	1997 BLUEBELL DRIVE		TELEPHONE:	(707) 800-2522
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 6		CENSUS: 6	DATE:	04/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Liza Fonseca-Lead Staff		TIME VISIT/ INSPECTION COMPLETED:	03:00 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	Licensing Program Analysts (LPA) Alviso conducted a Required- 1 Year visit, on 4/15/25 at approximately 10:20am, and was greeted by lead staff Liza Fonseca. LPA observed a second caregiver, Ashley, working at the facility. Lead staff Fonseca has a current RCFE administrator certificate. There are six (6) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for six (6) residents. Facility has a required infection control plan. Facility has a required emergency and disaster plan. Facility has a fire clearance approval for a total of six non-ambulatory, of which one (1) may be bedridden. Room #1 and #2 are fire cleared for bedridden use. Fire extinguishers were serviced and tagged as required. Facility has a carbon monoxide detector that worked properly during the inspection. All smoke alarms are hard wired and worked properly during the inspection. All exits were clear and unobstructed. The facility does have emergency food, water, and supplies to meet the "72 hour shelter in place" requirements. Per review of records, emergency disaster drills have been conducted as required; Last emergency disaster drills were conducted on 3/19/2025. LPA toured the facility with lead staff Liza. All exits were observed to be free and clear of obstruction. The LPA observed that the home was at a comfortable temperature for residents in care. The hot water was measured at 110.1 degrees Fahrenheit, which is within regulation. The bathrooms had grab bars and non-slip mats/flooring for resident use. There was sufficient lighting in all resident rooms, hallways, bathrooms, and common areas. Sufficient food supply of perishable and non-perishable food items. Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BLUEBELL MANOR	FACILITY NUMBER: 496804239
	VISIT DATE: 04/15/2025

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LPA observed the staff preparing the residents noon meal; LPA observed the residents having their noon meal during the inspection. There was a sufficient supply of furnishings for resident use. Sufficient supply of linens, cleaners/soap/disinfectants, hygiene products, paper products, and personal protective equipment (PPE) supplies. Medications were centrally stored and locked making them inaccessible to residents in care. Disinfectants/cleaners were observed to be locked up and inaccessible to the residents in care. The backyard was observed to be clean, orderly, and all pathways clear and free of obstruction. Fire exit gate was clear and unobstructed. The facility was observed to be clean and orderly during the inspection.

LPA reviewed six (6) resident files, including medical assessments and medication records.
LPA reviewed five (5) staff files. All staff have required criminal record clearance. Staff have required training. Staff have required first aid and CPR certification.

LPA is requesting the following documents be updated and submitted by 5/15/25.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E- Emergency Disaster Plan (ensure to review and update as needed/required- submit copy of review page or if changes submit copy of the plan.
Infection Control Plan (ensure to review and update as needed/required- submit copy of review page or if changes submit copy of the plan.
Copy of LIC400- Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

There are no deficiencies cited today.
Exit interview was conducted with Lead Staff Liza Fonseca.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

LIC809 (FAS) - (06/04)

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