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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208989
Report Date: 08/03/2021
Date Signed: 08/03/2021 02:16:53 PM

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-MATUSFACILITY NUMBER:
107208989
ADMINISTRATOR:GONZALES, MARILENFACILITY TYPE:
740
ADDRESS:7947 NORTH MATUS AVETELEPHONE:
(559) 259-6228
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Administrator, Marilen GonzalesTIME COMPLETED:
12:05 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 08/03/2021, Licensing Program Analysts (LPAs) A. Walton and M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPAs met with Administrator, Marilen Gonzales and stated the purpose of the visit. Facility has one central entry and exit. Upon entry to the facility, LPAs observed visitor log-in/temperature check. Facility staff observed to be wearing facial coverings. Residents wear facial coverings will out in the community.

Facility tour was conducted with Administrator. All entrances, exits, and pathways were free from obstructions. No fire clearance issues observed during today's inspection. LPAs observed signs at the entrance promoting social distancing, cough/sneeze etiquette, and hand-washing. LPAs observed reminders to wash hands in facility bathrooms. 4 bedrooms are single occupant, 1 bedroom is shared. LPAs observed beds in the shared bedroom to be at least 3 feet apart with head to toe orientation. Bathrooms were stocked with paper towels and liquid soap. LPAs did not observe trash cans with a lid.

LPAs observed a 30 day supply of medications. Medications are locked and inaccessible to residents in care. Food supply checked. LPAs observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. Facility has a 30 day supply of cleaning supplies. LPAs did not observe a 30 day supply of PPE supplies. Resident records were reviewed for updated emergency contact information. Staff records were reviewed for good health and infection control training.

No deficiencies observed during this inspection.

Exit interview conducted with Administrator. As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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