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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209190
Report Date: 03/08/2024
Date Signed: 03/12/2024 03:20:39 PM


Document Has Been Signed on 03/12/2024 03:20 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:BELLA CARE HOME LLC FARMHOUSEFACILITY NUMBER:
107209190
ADMINISTRATOR:GONZALES, PHILLIPFACILITY TYPE:
740
ADDRESS:1131 FARMHOUSE AVE.TELEPHONE:
(559) 259-6228
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 6DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Marilen Gonzales, AdministratorTIME COMPLETED:
02:05 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 03/08/2024, Licensing Program Analyst (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured the facility with staff Misty Lopez. Administrator (AD) Marilen Gonzales was notified of Licensing visit over the phone and arrived shortly to attend the visit. AD certification number 6055102740 and expiration date 8/12/2024.

The facility was observed to be at a comfortable temperature, of 75 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed most residents in common area during lunch watching television, others in their private room . Department phone number and infection prevention information signs were posted thought the facility.

Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

A fire extinguisher was observed with a service date of 02/05/2024. All residents’ bedrooms were observed to be at comfortable temperatures. The bathroom’s water temperature was tested and recorded reading of 114 degrees F.

Medications observed to be locked in a cabinet in the common area. LPA reviewed medication records appears to be administered properly. Cleaning supplies were observed to be in a locked cabinet in the storage it the laundry room. An outdoor seating area was observed operational for residents in care.

Report continues on LIC809-C
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BELLA CARE HOME LLC FARMHOUSE
FACILITY NUMBER: 107209190
VISIT DATE: 03/08/2024
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
Residential Care Facility for the Elderly (RCFE):
· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 3/20/2024

LPA reviewed staff and residents’ files. No deficiencies were observed and cited.



Exit interview conducted. A report was signed, and a copy of this report was provided for facility records.

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2