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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208861
Report Date: 06/20/2022
Date Signed: 06/20/2022 12:59:10 PM


Document Has Been Signed on 06/20/2022 12:59 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:
06/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Caregiver, Marissa MasangcayTIME COMPLETED:
01:15 PM
NARRATIVE
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On 06/20/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Marilen Gonzales via telephone. Administrator is unable to attend today's visit, LPA received verbal permission from Administrator to meet with Caregiver, Marissa Masangcay.

The purpose of today's visit is to follow up on documentation of staff training submitted to the Fresno CCL office.

LPA reviewed records and conducted interviews. LPA requested for Administrator to provide copies of the original certificates, training attendance records and training materials. Facility Administrator is unable to produce the requested documentation today. An interview with the Administrator revealed that the Administrator does not have documentation of training conducted with facility staff that includes the following: date and time training was conducted, training topics and materials, extent of the training, and a signature from staff acknowledging training was conducted.

Based on record review and interviews, a deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a Plan of Correction was reviewed and developed with Administrator via telephone. A copy of this report and appeal rights were discussed and provided to Caregiver, Marissa Masangcay, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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Document Has Been Signed on 06/20/2022 12:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - HOUSTON
FACILITY NUMBER: 107208861

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2022
Section Cited

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87412 Personnel Records: (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement was not met as evidenced by:
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Based on interviews and records review, the Licensee did not maintain records that verified required staff training for 4 out of 4 staff. This poses an potential health and safety risks 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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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