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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206822
Report Date: 08/25/2022
Date Signed: 08/25/2022 11:29:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2022 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20220819112351
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:
08/25/2022
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Administrator, Marilen GonzalesTIME COMPLETED:
11:49 AM
ALLEGATION(S):
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Staff do not have required training
INVESTIGATION FINDINGS:
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On 8/25/22 Licensing Program Analyst (LPA) M. Garza arrived at faciilty to complete an unannounced initial 10 day visit. LPA introduced self, was COVID pre-screened and was permitted into facility. Administrator, Marilen Gonzales was contacted and arrived some time later. LPA toured facility inside and out. A Health and Safety check was completed on residents in care. Residents observed visiting family outside and in common area.

During visit LPA requested documentation, completed interviews and reviewed 7 staff files. LPA observed 5 of 7 staff files do not have the required training.

The allegation listed above is SUBSTANTIATED. Deficiencies on LIC 9099D. Exit interview completed. A copy of this report and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20220819112351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2022
Section Cited
CCR
87707(a)
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87707 Training requirements...(a) Licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia...shall ensure that all direct care staff...who provide care to residents with dementia, meet the following training requirements...
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Licensee will provide training to all staff, if not already completed. A copy of training records and material will be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA observation in that 5 of 7 staff files reviewed did not have the required training. This posses a potential health and safety/personal rights risk to residents in care.
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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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2