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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208989
Report Date: 09/19/2022
Date Signed: 09/19/2022 01:21:54 PM


Document Has Been Signed on 09/19/2022 01:21 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-MATUSFACILITY NUMBER:
107208989
ADMINISTRATOR:GONZALES, MARILENFACILITY TYPE:
740
ADDRESS:7947 NORTH MATUS AVETELEPHONE:
(559) 259-6228
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Caregiver, Martin Salcedo and Caregiver, Johanna LorioTIME COMPLETED:
01:35 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 09/19/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator via telephone. Administrator stated she is unavailable to attend this inspection and gave verbal permission to meet with facility staff. LPA met with Caregiver, Martin Salcedo and Caregiver, Johanna Lorio.

Facility tour was conducted with Caregiver, Salcedo. All entrances, exits, and pathways were free from obstructions. No fire clearance issues observed during today's inspection. LPA observed signs at the entrance promoting social distancing, cough/sneeze etiquette, and hand-washing. LPA 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. LPA observed a trash can with lid in 1 out of 3 bathrooms.

LPA observed a 30 day supply of medications. Medications are locked and inaccessible to residents in care. Food supply checked. LPA 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. LPA 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.

CONTINUED TO 809C
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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 2


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-MATUS
FACILITY NUMBER: 107208989
VISIT DATE: 09/19/2022
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
26
27
28
29
30
31
32
LPA is requesting the following documents be submitted to the Fresno CCL office by 10/03/2022: 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

No deficiencies issued during today's inspection.

Exit interview conducted. A copy of this report was discussed and provided to Caregiver, Martin Salcedo, 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: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2