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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881098
Report Date: 04/11/2022
Date Signed: 04/11/2022 01:35:55 PM


Document Has Been Signed on 04/11/2022 01:35 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:BELL'S COTTAGEFACILITY NUMBER:
331881098
ADMINISTRATOR:SIMMONS-ROBINSON, LAVONFACILITY TYPE:
740
ADDRESS:26272 KATHY LANETELEPHONE:
(951) 392-3397
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:6CENSUS: 0DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Lavon Simmons-Robinson, AdministratorTIME COMPLETED:
01:40 PM
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Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPAs met with Administrator Lavon Simmons-Robinson and explained the purpose of today's visit. There are currently no residents residing at the facility.
During the inspection, LPAs interviewed Simmons-Robinson regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPAs observed appropriate postings in the facility, including COVID-19 symptoms postings, which were in accordance with the Department's guidelines. LPAs observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and ensuring that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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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