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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208861
Report Date: 06/11/2021
Date Signed: 06/18/2021 09:55:22 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 LLC - HOUSTONFACILITY NUMBER:
107208861
ADMINISTRATOR:GONZALES, MARILENFACILITY TYPE:
740
ADDRESS:2660 EAST HOUSTON AVETELEPHONE:
(559) 259-6228
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
06/11/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Caregiver, Marissa MasangcayTIME COMPLETED:
11:26 AM
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On 6/11/2021, Licensing Program Analyst (LPA) arrived unannounced at the above facility. LPA introduced self and stated the purpose of the visit. LPA met with Caregiver Marissa Masangcay.

The purpose of today's visit is to drop of requested PPE supplies for the facility.

No deficiencies issued.

An exit interview was conducted. As a COVID-19 precautionary measure, a copy of this report was provided to licensee via email and an electronic read receipt confirms receiving this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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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