<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206822
Report Date: 06/21/2021
Date Signed: 07/14/2021 11:02:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BELLA CARE HOME LLCFACILITY NUMBER:
107206822
ADMINISTRATOR:MARILEN GONZALESFACILITY TYPE:
740
ADDRESS:491 PIERCE DRTELEPHONE:
(559) 472-3575
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:6CENSUS: 6DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Administrator, Marilen GonzalesTIME COMPLETED:
04:47 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
On 05/28/2021, Licensing Program Analyst, M. Garza arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA was greeted by live in staff, Shirley Alaysa and was allowed entry into the facility. Administrator, Marilen Gonzales arrived a short time later. LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. Residents observed in common area and in room.

Mitigation plan not approved prior to visit but has been submitted to CCL 12/2020 pending approval. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA's toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed throughout the facility. Staff observed not wearing face coverings. Facility has designated visitation areas. Covered trash bins were observed. LPA observed a supply of PPE and resident medications. Sinks stocked and liquid soap for hand washing and paper towels for hand drying were observed.

Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices are not found to be in compliance. Technical Advisory and citation was issued during todays inspection. Exit interview completed with Administrator. An immediate civil penalty was issued of $100 for un-fingerprinted adult.

A copy of this report was sent via email for signature. A delivered and read receipt was sent as confirmation of receipt.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BELLA CARE HOME LLC
FACILITY NUMBER: 107206822
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, staff was observed working in facility and was not finger print cleared or associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2021
Plan of Correction
1
2
3
4
Remove staff immediately until finger print cleared/associated.
Type A
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation LPA observed residents door locks taped preventing resident from asscessing them which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2021
Plan of Correction
1
2
3
4
Administrator stated she will remove tape immediately, train staff and provide CCL copy of training discussed and sign in sheet no later than 6/28/21.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BELLA CARE HOME LLC
FACILITY NUMBER: 107206822
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(A)
Personal Accommodations and Services
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation LPA observed residents room without a bed and only a couch which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2021
Plan of Correction
1
2
3
4
Administrator stated they will provide Physicians Report, Pysicians presricption and letter requesting exemption for resident to have couch in lieu of a bed.
Type B
Section Cited
CCR
87705(b)(2)
Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation LPA observed front entry door, back sliding door and entry to garage door from house with auditory alarms turned off which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2021
Plan of Correction
1
2
3
4
Administrator immediately turned on back door and front door auditory alarms. Administrator stated they would replace garage door entry with a new auditory alarm. Admnistrator to provide verification of purchase/change to CCL no later than 6/28/21.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3