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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202386
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:23:38 PM


Document Has Been Signed on 08/30/2022 02:23 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:ROSEBELLA PLACEFACILITY NUMBER:
157202386
ADMINISTRATOR:DALERE, GRACE AFACILITY TYPE:
740
ADDRESS:9319 MANIHIKITELEPHONE:
(661) 855-4500
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 6DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Amilyn Aguil, AdminstratorTIME COMPLETED:
02:37 PM
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On 08/30/22, Licensing Program Analyst (LPA) L. Salazar arrived unannounced to conduct the required Annual - Infection Control Inspection. LPA was greeted by caregiver, stated purpose of visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry. LPA entered through the central entry point where hand sanitizer and visitor policy was posted. LPA observed the Staff and Visitor sign in and Covid Symptom Screening area.

Facility Mitigation plan has been submitted to CCL. Infection control procedures described in the plan were observed and reviewed with LPA include: Daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, emergency staffing plan, PPE storage, use and training, as well as daily infection control procedures. Administrator is identified as the Infection Control lead for the facility.

LPA toured the facility and observed postings to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Staff was observed wearing face coverings. Facility has multiple designated visitation areas available. LPA observed PPE accessible to staff. Common and resident bathroom sinks are well stocked with liquid soap and paper towels for hand washing.

Through LPA’s observations, documentation review and interview with Administrator , the required infection control practices are found to be in compliance. No deficiencies cited on today’s inspection.

(Continued on 809-C)
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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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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: ROSEBELLA PLACE
FACILITY NUMBER: 157202386
VISIT DATE: 08/30/2022
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    (Continued from 809)

    The following documents are requested and need to be submitted to Fresno
    CCL by 9/16/2022. Designation of Facility Responsibility (LIC308) Administrator Organization (LIC309) Personnel Report (LIC500) Emergency and Disaster Plan (LIC610ES), and Register of Facility Clients (LIC9020).

    An exit interview was conducted with Administrator and a copy of the report was provided at the time of visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
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