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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804142
Report Date: 07/06/2023
Date Signed: 07/06/2023 10:28:06 AM

Document Has Been Signed on 07/06/2023 10:28 AM - 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:LA BELLA MANORFACILITY NUMBER:
496804142
ADMINISTRATOR:KAMAU, JOYCE M.FACILITY TYPE:
735
ADDRESS:4339 PRINCETON WAYTELEPHONE:
(707) 206-2169
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 4CENSUS: 0DATE:
07/06/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Joyce KamauTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived announced at La Bella Manor for the purpose of conducting a Pre-Licensing Inspection. LPA was greeted at the door by Licensee, Joyce Kamau, and was granted access into the facility. The facility is approved for 4 Ambulatory Clients. Administrator presented the LPA with the Administrators Certificate for Adult Residential Facility Administrator Program (Standard Certificate #6004236735 with an expiration of 05/03/2025).

LPA and Licensee toured the one story facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. Fire Extinguisher was found to be last charged on November 2022. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the Pre-Licensing inspection. Hot water temperature measured at 115 degrees in 2 of 2 clients bathrooms and is within Title 22 regulation. Sample food menu was observed on the refrigerator. Activities Menu was observed in the hallway. LPA observed sufficient perishable and non-perishable foods located in the refrigerator and pantry. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Client records, personnel records and medications will be locked and in separate cabinets which are inaccessible to clients in care. Hazardous items and toxins are kept locked in the closet hallway and inaccessible to clients in care. Facility has a first aid kit which was inspected and found to be appropriate during the Pre-Licensing inspection. There is an outdoor space for activities with a shaded area for clients in care. LPA observed a garden in the backyard that will be utilized for activities. Emergency Disaster plan was discussed with the Licensee. During the Pre-Licensing inspection, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Infection Control Plan was most recently updated on June 30, 2023 and mailed to the Centralized Applications Bureau (CAB) Unit Analyst. All staff will be trained in the Emergency Disaster and PPE training.

Component III was waived due to already being licensed. Exit interview was conducted, and a copy of this report was given to the Licensee. LPA will forward this report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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