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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209315
Report Date: 06/13/2023
Date Signed: 07/20/2023 10:55:44 AM

Document Has Been Signed on 07/20/2023 10:55 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:BELLA HOME SENIOR CAREFACILITY NUMBER:
547209315
ADMINISTRATOR:FELIX, MARIA EVAFACILITY TYPE:
740
ADDRESS:1968 W MONACHE AVETELEPHONE:
(559) 544-2725
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: DATE:
06/13/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Maria Eva FelixTIME COMPLETED:
02:45 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): zero
COMP II Participants: Maria Eva Felix
Interview Method: Telephone interview over phone

On June 13, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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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