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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200412
Report Date: 05/03/2022
Date Signed: 05/03/2022 03:32:28 PM

Document Has Been Signed on 05/03/2022 03:32 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BELL'S FAMILY HOME, INC.FACILITY NUMBER:
019200412
ADMINISTRATOR:DELLA A. BREWERFACILITY TYPE:
735
ADDRESS:4511 MATTIS COURTTELEPHONE:
(510) 336-9865
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY: 6CENSUS: 4DATE:
05/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Wanda Sheppard, AdminstratorTIME COMPLETED:
03:50 PM
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On 5/3/22 at 2:15pm, Licensing Program Analysts (LPAs) K.Nguyen, and C. Lin arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Wanda Sheppard and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit. Exit interview conducted with administrator and a copy of this report will be provided vis email, due to copier technical issue.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
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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