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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208861
Report Date: 05/09/2022
Date Signed: 05/09/2022 02:12:58 PM


Document Has Been Signed on 05/09/2022 02:12 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
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:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Caregiver, Marissa MasangcayTIME COMPLETED:
02:14 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 05/09/2022, Licensing Program Analyst (LPA) Walton arrived unannounced at the above facility to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and was granted entry to the facility by Caregiver, Marissa Masangcay. Caregiver contacted Administrator, Marilen Gonzales via telephone. Administrator is unable to attend this inspection, LPA received verbal permission from Administrator to meet with Caregiver, Marissa Masangcay.

LPA conducted a facility tour with Caregiver. Facility appeared to be clean. There are 6 residents present during today's inspection. Staff were not observed to be wearing facial masks, staff did put on a mask during the inspection. Residents observed to be at least 6 feet apart in common areas. Facility is sanitized at least once daily. LPA observed one hand sanitizer dispenser located at the main entrance. LPA did not observe signs promoting hand-washing, cough/sneeze etiquette, and physical distancing, signs were posted during the inspection by facility staff.

LPA toured the resident bedrooms. Facility has one shared bedrooms, and the remaining 4 bedrooms are single occupant. LPA observed beds in the shared bedroom to be at least 6 feet apart. Resident bathrooms were equipped with paper towels and liquid soap. Hand-washing signs were not observed in the bathrooms. LPA observed an adequate supply of food. Cleaning and PPE supplies was observed. Facility has a 30 day supply of resident medications. LPA reviewed personnel records for good health. LPA did not observe up to date training in the personnel files. Resident records have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 05/23/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A) Surety Bond

Exit interview conducted. A copy of this report will be discussed and provided to Caregiver, Marissa Masangcay, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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 1