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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804215
Report Date: 04/12/2024
Date Signed: 04/15/2024 12:37:55 PM

Document Has Been Signed on 04/15/2024 12:37 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BELLA STELLA COMMUNITY HOMEFACILITY NUMBER:
486804215
ADMINISTRATOR/
DIRECTOR:
JONATHAN KIESLERFACILITY TYPE:
735
ADDRESS:342 LARKIN DRIVETELEPHONE:
(502) 548-6320
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 4CENSUS: 0DATE:
04/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:38 PM
MET WITH:Jonathan Kiesler, Co- Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:54 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived to conduct a pre-licensing inspection and was greeted by co-licensee/Administrator, Jonathan Kiesler and co-licensee, George Portan.

At approximately 1:40PM LPA and Administrator toured the building and grounds. The home is clean, organized, at a comfortable temperature with all exits free from obstruction. Facility is a two story residence with four bedrooms and two bathrooms upstairs. Three of the bedrooms, bathroom will be used by clients and the master bedroom/bathroom will be used by staff. The main level of the home is made of two family rooms, dining room, kitchen, bathroom, garage and an indoor back patio. All client rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPA observed several snacks available in kitchen. Cleaning supplies and toxins are inaccessible to clients. Facility has areas inside and outside for visiting and activities. There was an appropriate supply of linens, hygiene products and paper products available for clients.

Facility received an approved fire clearance dated January 16, 2024 for four (4) ambulatory clients by the Benicia Fire department. LPA observed charged fire extinguishers in every floor that were purchased on 1/15/2024. Smoke detectors and carbon monoxide detectors were observed. Facility has an Infection Control plan and Emergency Disaster Plan on file. Hot water temperatures found to be within Title 22 Regulations of 105 to 120. Administrator Certificate 6067485735 for Jonathan Kiesler expires 8/28/2025.

No Deficiencies or Advisories given during visit. Pre-Licensing inspection is complete. Component III was conducted with Applicant.
LPA will then submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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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