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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206822
Report Date: 04/08/2025
Date Signed: 04/08/2025 04:14:52 PM

Document Has Been Signed on 04/08/2025 04:14 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BELLA CARE HOME LLCFACILITY NUMBER:
107206822
ADMINISTRATOR/
DIRECTOR:		MARILEN GONZALESFACILITY TYPE:
740
ADDRESS:491 PIERCE DRTELEPHONE:
(559) 472-3575
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
04/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Marilen Gonzales and Ann TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daiquiri Boyd arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by staff and explained the purpose of the visit. Licensee/Administrator Marilen Gonzales responded to the facility to assist with the visit. LPA completed the inspection with staff Ann Lorio.
LPA toured the home inside and outside. No exits were found to be obstructed. Temperature of the home was set at 73 degrees F.
Last Fire and Emergency Drill was conducted on 3/2/25. Fire extinguisher serviced on 2/7/2025.
The home has 5 bedrooms and 2 bathrooms. All bedrooms are nicely furnished with personal affects, beds, tv's, chairs, lighting, dressers, bedside tables, and ceiling fans. Bathrooms delivered hot water at a temperature of 115 degrees F. Fire place is not used.
LPA observed a fresh supply of fruits and vegetables, perishable and non-perishable foods.
LPA did not observe a supply of emergency food and water. Disaster drill needs more information and LPA requested more details be added to the Emergency and Disaster Plan.
LPA requests that an updated floor plan with location of utility shut-off's be provided to Licensing.
LPA observed the home to be in good condition with flooring, walls, lighting, counter tops, fixtures, all in good working order. LPA observed a supply of linens in the hall way closet. All hazardous chemicals and item are kept stored in a locked hall closet. The washer and dryer are kept in the hall way area. LPA spoke to staff regarding keeping this area clean and the dryer properly maintained to avoid a build-up of lint.
Smoke and carbon monoxide detectors were observed and checked and found to be in working order.
The upstairs area of the home is designated at staff only as LPA verified by observation.
Resident medications and medication records were reviewed. LPA reviewed four resident files and four staff files. (continued on next page)
Sergiy PidgirnyTELEPHONE: (559) 243-8080
Daiquiri BoydTELEPHONE: 559-243-8080
DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BELLA CARE HOME LLC
FACILITY NUMBER: 107206822
VISIT DATE: 04/08/2025
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Back yard area is clean and free of hazards, pool on premises has a locked fence and gate. The back yard has two sheds, neither contains any hazards as observed by LPA.
LPA requests that updated forms be sent to CCL by 4/18/25: LIC500, LIC610D, Liability Insurance, LIC308.
Signature of staff confirms receipt of this document.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Daiquiri BoydTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
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