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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206822
Report Date: 03/28/2022
Date Signed: 04/22/2022 11:30:09 AM


Document Has Been Signed on 04/22/2022 11:30 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, 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: 5DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Licensee Marilen GonzalesTIME COMPLETED:
04:44 PM
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On 03/28/2022 Licensing Program Analyst, M. Garza arrived at the facility unannounced to conduct the required Infection Control Inspection. Administrator was contacted and arrived a short time later. LPA was greeted by Direct Care Staff and COVID pre-screened. LPA was permitted entry into the facility. 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. Resident observed in room.

Mitigation plan was received and reviewed. COVID-19 procedures described in the plan include required postings, symptoms screenings (for staff, persons in care and visitors), testing, quarantine/isolation cohorts, infection control plan to include donning and doffing of Personal Protective Equipment. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed. Staff were all observed wearing face coverings. Facility has designated visitation areas. Covered trash bins were observed. LPA observed 2 of 4 residents with a 30-day supply of resident medications. A 30 day supply of PPE not observed. Licensee has available at different location. LPA did not observe N95 masks/surgical masks. Licensee to provided additional PPE. Sinks are well 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 found to be in compliance.

Due to COVID precautionary measures a copy of this report will be emailed to: bellacarehomellc@gmail.com. A delivered and read receipt serves as confirmation.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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