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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202386
Report Date: 07/24/2023
Date Signed: 07/24/2023 12:09:23 PM


Document Has Been Signed on 07/24/2023 12:09 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:ROSEBELLA PLACEFACILITY NUMBER:
157202386
ADMINISTRATOR:DALERE, GRACE AFACILITY TYPE:
740
ADDRESS:9319 MANIHIKITELEPHONE:
(661) 855-4500
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 5DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Assistant Administrator Amilyn “Amy” Aguil and caregiver Maria OrtizTIME COMPLETED:
12:15 PM
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On 07/24/23, Licensing Program Analyst (LPA) Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by caregiver Maria Ortiz. LPA was granted entry into the facility. Administrator Grace Dalere was called and stated unable to attend meeting. Administrator stated Assistant Administrator (AA) Amilyn “Amy” Aguil will attend meeting. AA arrived shortly. LPA toured facility with caregiver and AA. All five residents was during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Fire extinguisher was observed with a service date of: 04/03/23. Fire drill last completed: 06/19/23. An adequate supply of perishable and non-perishable food was observed. Cleaning supplies were observed stored under locked kitchen sink and laundry closet. Knives and sharps stored and locked in kitchen drawer. First Aid Kit was observed with all required items. Medications were observed locked under television drawers. MARs were reviewed. LPA toured all residents’ bedrooms and observed 5 single occupant rooms. Residents’ room observed to be adequately furnished with bed, dresser, and adequate lighting. Bathrooms were properly equipped, and the hot water temperature was tested at 109.5 degrees F in master bathroom and 112.2 degrees F in bathroom. Outside toured and observed to be free of debris with adequate seatings available for residents. Side gate observed self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. All residents’ file reviewed to have update emergency contacts, Admission agreement, and Pre-Appraisal. A sample of staff files were also reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.

No deficiency cited during inspection. The following documents are requested and submitted to Fresno CCL by: 08/01/23. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 9282, current liability insurance, control of property, updated facility sketch, and current Administrator certificate. A copy of this report was provided to AA and via email to Administrator as requested.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
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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