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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700710
Report Date: 01/21/2022
Date Signed: 01/24/2022 04:16:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BELLA NOVA RCFEFACILITY NUMBER:
342700710
ADMINISTRATOR:TEDLOS, BRIANFACILITY TYPE:
740
ADDRESS:8797 TWINBERRY WAYTELEPHONE:
(916) 667-3248
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
01/21/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Mary Grace DeleonTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the care home to conduct an unannounced Annual Inspection. Facility Administrator Brain Tedlos was contacted by phone and informed of the purpose of the visit and Facility Manager Mary Grace Deleon was able to assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. The facility has submitted a written mitigation plan (LIC 808) and LPA reviewed and discussed the plan and current Licensing guidance..

LPA toured the facility and reviewed the Mitigation Plan as well as discussing COVID Training Procedures during the Inspection. Smoke alarms and smoke detectors are hard wired to the facility, were tested are operational. Fire extinguishers were serviced in October 2021and are in compliance and are due to be serviced next month. Facility has carbon monoxide detectors that were tested and are operational. Medication were locked and facility was determined to have an adequate food supply. Facility's PPE supplies were observed and determined to be adequate for a 30 supply.

The interior and outdoor area of the home was inspected including bedrooms, kitchen, bathrooms, and common areas for this home. There are five clients in the home and 6 client bedrooms, There are two client bathrooms that were viewed and are in compliance with grab bars and non-skid mats. Water temperature was measured at 117.5 degrees and is in compliance.

Continued
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BELLA NOVA RCFE
FACILITY NUMBER: 342700710
VISIT DATE: 01/21/2022
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All staff on site have the required criminal record clearance. LPA observed the following posted in the facility: Hand washing and visitation policies, Visitation signs. Resident Personal Rights, Evacuation Routes and facility license were all posted as required. Current LIC 500, LIC 308, and LIC 309 to be updated and submitted to Licensing as needed

Exit interview conducted with Mary Grace, no deficiencies were identified and a copy of report given at the conclusion of the visit
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC809 (FAS) - (06/04)
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