Bluebell Manor

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Alviso conducted a Required- 1 Year visit, on 6/22/26 at approximately 9:45am, and met with Administrator Bana Solomon. There are six (6) residents in care; One resident is on hospice care. LPA observed two (2) caregivers on duty during the inspection. Facility has a fire clearance approval for a total of six non-ambulatory, of which one (1) may be bedridden. Room #1 and #2 are fire cleared for bedridden use. Fire extinguishers were serviced and tagged as required. All smoke alarms are hard wired and working properly, including the carbon monoxide detector. All exits were observed to be clear and unobstructed. Facility has a dementia plan of operation. There is an approved hospice waiver for six (6) residents. Facility has a required infection control plan. Facility has a required emergency and disaster plan. The emergency disaster drills are being conducted as required, per file review. LPA reviewed six (6) resident records, including medication records; LPA observed the storage of all medications. LPA reviewed five (5) staff files, including training. All staff have DOJ criminal record clearance as required. All staff have required training. All staff have required first aid certification and CPR certification. LPA toured the home with Administrator Bana Solomon. The facility was observed to be at a comfortable temperature. The home has central heating and air conditioning for use as needed. The facility has an in-ground stand-by generator for use in an emergency. Continued on LIV809C.. The facility has a sufficient supply of food. Facility was clean and orderly during the inspection. Facility had a sufficient supply of linens, furnishings, paper products, hygiene products, cleaners/disinfectants, and personal protective equipment (PPE) supplies. Medications were locked and inaccessible to residents, and others who are not trained medication staff. All cleaners/disinfectants were locked up and inaccessible to residents in care. LPA observed sufficient lighting throughout the facility for resident use. All bathrooms had grab bars and non-slip flooring/non-slip mats in showers for resident use. Facility had emergency water and food supplies to meet the "72 hour shelter in place" requirements. LPA is requesting the following documents be updated and submitted by 7/22/26: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E- Emergency Disaster Plan, 9 pages (review as required- submit copy of review page or if changes made, submit a copy) Infection Control Plan (review as required- submit copy of review page or if changes made, submit a copy) Copy of LIC400- Handling of Client Cash Resources (all facilities to complete the form) Copy of surety bond if handling cash (surety bond in amount required per LIC400) Copy of Current Liability Insurance Resident Roster Copy of current Administrator Certificate. There were no deficiencies cited during today's inspection. LPA conducted exit interview with the Administrator.the state’s words, verbatim · CDSS document, Jun 22, 2026

Allegation investigated: Staff do not have proper training

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, 4/15/25 at approximately 10:20am, and met with Lead staff Liza Fonseca. Lead staff Fomseca has a current RCFE administrator certificate. LPA reviewed staff records and obtained copies as requested. Reporting party alleges that the facility “staff do not have proper training”. LPA reviewed staff training records for six (6) staff (S2, S3, S4, S5, S6, S7) that were on the regular work schedule. Per record reviews, all six (6) staff have required trainings. There was no information obtained during this investigation to support a violation had occurred regarding reported allegation. Based on record reviews, interviews, and related information obtained during the investigation, the allegation “staff do not have proper training”, we have found that the complaint allegation is Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Unfoundedthe state’s words, verbatim · CDSS document, Apr 15, 2025 · control 21-AS-20250130095032

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Alviso conducted a Required- 1 Year visit, on 4/15/25 at approximately 10:20am, and was greeted by lead staff Liza Fonseca. LPA observed a second caregiver, Ashley, working at the facility. Lead staff Fonseca has a current RCFE administrator certificate. There are six (6) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for six (6) residents. Facility has a required infection control plan. Facility has a required emergency and disaster plan. Facility has a fire clearance approval for a total of six non-ambulatory, of which one (1) may be bedridden. Room #1 and #2 are fire cleared for bedridden use. Fire extinguishers were serviced and tagged as required. Facility has a carbon monoxide detector that worked properly during the inspection. All smoke alarms are hard wired and worked properly during the inspection. All exits were clear and unobstructed. The facility does have emergency food, water, and supplies to meet the "72 hour shelter in place" requirements. Per review of records, emergency disaster drills have been conducted as required; Last emergency disaster drills were conducted on 3/19/2025. LPA toured the facility with lead staff Liza. All exits were observed to be free and clear of obstruction. The LPA observed that the home was at a comfortable temperature for residents in care. The hot water was measured at 110.1 degrees Fahrenheit, which is within regulation. The bathrooms had grab bars and non-slip mats/flooring for resident use. There was sufficient lighting in all resident rooms, hallways, bathrooms, and common areas. Sufficient food supply of perishable and non-perishable food items. Continued on LIC809C... LPA observed the staff preparing the residents noon meal; LPA observed the residents having their noon meal during the inspection. There was a sufficient supply of furnishings for resident use. Sufficient supply of linens, cleaners/soap/disinfectants, hygiene products, paper products, and personal protective equipment (PPE) supplies. Medications were centrally stored and locked making them inaccessible to residents in care. Disinfectants/cleaners were observed to be locked up and inaccessible to the residents in care. The backyard was observed to be clean, orderly, and all pathways clear and free of obstruction. Fire exit gate was clear and unobstructed. The facility was observed to be clean and orderly during the inspection. LPA reviewed six (6) resident files, including medical assessments and medication records. LPA reviewed five (5) staff files. All staff have required criminal record clearance. Staff have required training. Staff have required first aid and CPR certification. LPA is requesting the following documents be updated and submitted by 5/15/25. LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E- Emergency Disaster Plan (ensure to review and update as needed/required- submit copy of review page or if changes submit copy of the plan. Infection Control Plan (ensure to review and update as needed/required- submit copy of review page or if changes submit copy of the plan. Copy of LIC400- Handling of Client Cash Resources (include copy of surety bond if handling cash) Copy of Current Liability Insurance Resident Roster Copy of current Administrator Certificate. There are no deficiencies cited today. Exit interview was conducted with Lead Staff Liza Fonseca.the state’s words, verbatim · CDSS document, Apr 15, 2025

Allegation investigated: Insufficient food supply

Licensing Program Analysts (LPAs) Alviso and Magdaleno, conducted a complaint inspection, on 1/30/2025 at approximately 12:40pm, and met with caregiver Monica Balderas. Reporting party alleges that the facility has an “Insufficient food supply”. LPAs observed the food supply; Food supply was found to be sufficient in perishable food and non-perishable foods. Interview with S2 identified that there is always food for resident meals, snacks, and drinks for residents in care; Staff stated that there is no concern regarding food supply to feed residents their meals. Per interviews with staff and other related parties, the food supply is sufficient and meals, drinks, and snacks are provided to all residents in care. LPAs observed numerous food items, frozen meats, vegetables, and other items for meals to be prepared. LPA has observed staff cooking meals for the residents in care during inspections recently completed.There was no information obtained during this investigation to support a violation had occurred regarding reported allegation.Based on the interviews, LPA observations, and related information obtained during the investigation, the allegation “Insufficient food supply” is Unfounded". We have found that the complaint allegations was Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Jan 30, 2025 · control 21-AS-20250130095032

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff does not ensure resident is provided a shower mat

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/29/2025 at approximately 10:00am, and met with Bana Solomon, Administrator/Licensee. LPA reviewed resident files, staff files, and conducted interviews with staff (S1, S2, S3) and other related parties. LPA toured the facility with staff. Reporting party alleges that “staff does not ensure resident is provided a shower mat”. Per interviews with staff and other related parties on 11/13/24, the investigation revealed that shower mats had been removed from showers in the facility, for an unknown time frame, and staff were directed to use towels on the shower floor when showering residents. Per interviews with staff and other related parties, non-slip mats had recently been brought back into the facility within the last few weeks from the LPA's inspection, 11/13/24. LPA discussed regulations regarding maintenance and operation, and resident rights/personal rights with staff interviewed. Continued on LIC9099C.. Substantiated Per investigation, there is sufficient information obtained to support a violation had occurred. Per LPA’s investigation, review of records, including interviews with staff, and interviews with other related parties, the “staff does not ensure resident is provided a shower mat” is Substantiated. The following deficiencies will be cited: Maintenance and Operation 87303(e)(5)(A)- Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors, see LIC9099D. 87468.1(a)(2) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment, see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator/Licensee.. Appeal Rights Provided. Interviews with staff, and other parties found no information of residents being forced to shower. No information obtained of residents needs not being met by facility staff. In review of records, and interviews conducted, there was no information obtained regarding records having been falsified. Per investigation, there was not sufficient information obtained to support violations had occurred. Based on the LPA’s investigation, observations, interviews with staff and other related parties, the investigation, the allegations of “facility does not have adequate staffing to meet resident's needs, staff force residents to shower, staff do not ensure residents are provided a comfortable temperature, and staff falsify resident's records” are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Bana Solomon.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 21-AS-20241108132545

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(5)(A · Plan of correction due date: Feb 3, 2025

: Maintenance and Operation 87303(e)(5)(A)-Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement was not met as evidenced by: LPA's investigation, interviews with staff, and other related parties. Bath mats had been removed for an unknown time frame, staff were directed to use towels on the shower floor for resident showers. This is a risk to residents personal rights and to health & safety of residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: POC CLEARED BY ADMINISTRATOR/LICENSEE PUTTING BATH MATS IN ALL BATHROOM SHOWER STALLS/TUBS. LICENSEE STATED THEIR UNDERSTANDING OF THE REGULATION. POC CLEARED 2/3/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 10, 2025

87468.1(a)(2) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment, This requirement was not met as evidenced by: LPA's investigation, interviews with staff, and other related parties. Bath mats had been removed for an unknown time frame, staff were directed to use towels on the shower floor for resident showers. This is a risk to residents personal rights and to health & safety of residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee to ensure all staff obtain personal rights/residents rights training. Submit proof of training by 2/1/25, include trainers name, date/time spent, topics covered. POC due by 2/1/25.

Allegation investigated: Staff does not follow physician's orders Staff are over medicating the resident

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/29/2025 at approximately 10:00am, and met with Bana Solomon, Administrator/Licensee. Reporting party alleges that “staff does not follow physician's orders, and staff are over medicating the resident”. LPA reviewed resident files, staff files, and conducted interviews with staff (S1, S2, S3) and other related parties. LPA toured the facility with staff. LPA observed all of the residents in the facility, and met with some of the residents in care.LPA interviewed staff, and other related parties. Per investigation, review of records, interviews with the staff and other related parties, the investigation revealed that residents, R1 & R2, medications all have Dr's Orders, routine and PRN orders. Per interviews, with staff, and other related parties, medications are being provided as ordered. All medication records were found to be in order. Continued on LIC9099C.. Unsubstantiated Per investigation, there was not sufficient information obtained to support violations had occurred. Based on the LPA’s investigation, observations, interviews with staff and other related parties, the investigation, the allegations of “ “staff does not follow physician's orders, and staff are over medicating the resident” are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Bana Solomon.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 21-AS-20241112162814

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Hansen, conducted a pre-licensing inspection, on 6/?/24 at approximately ??8:00 AM, and met with applicant Bana Solomon, was unavailable for this mornings visit. Bana Solomon RCFE Administrator Certificate #6063962740 expires 8/12/2024. Facility is fire cleared for six(6) non-ambulatory, which includes one(1) bedridden, effective 3/19/24. Applicant has an approved Hospice Waiver for 6 Hospice Residents. Applicant has an approved dementia plan of operation. Applicant has submitted an infection control plan for the home as required. The last inspection was on 6/5/24 and there were a few items that needed to be completed; LPA has observed that the following items need to be corrected prior to being licensed. The east side exit door has not had keycode lock installed that leads out to field. And additional items discussed with Administrator. Bana Solomon completed component III orientation on 5/23/24. The applicant will contact LPA Hansen when the items and will be back listed above are complete; LPA will schedule another pre-licensing continued inspection to reinspect as needed. The applicant may contact the LPA at the contact number provided if there are any questions to the above information.the state’s words, verbatim · CDSS document, Jun 11, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Hansen, conducted a pre-licensing inspection, on 6/5/24 at approximately 8:00 AM, and met with Assistant Administrator Diandra Chadwick as applicant Bana Solomon, was unavailable for this mornings visit. Bana Solomon RCFE Administrator Certificate #6063962740 expires 8/12/2024. Facility is fire cleared for six(6) non-ambulatory, which includes one(1) bedridden, effective 3/19/24. Applicant has an approved dementia plan of operation. Applicant has submitted an infection control plan for the home as required. The last inspection was on 5/23/24 and there were a few items that needed to be completed; The LPA has observed that the following items are complete. The east & west front door ramp railings have been replaced, and west side ramp walkway has been evened out. Backyard deck has latching fence to keep residents in care from entering back field. Although east side exit door has not had keycode lock installed that leads out to field. Postings were not posted at todays visit, although LPA observed required postings. Bedrooms 4 & 5 do not have night stands or lights for light stands although rooms do have ceiling lights. Bathrooms do not have paper towels and front yard needs to be cleaned up. Bana Solomon completed component III orientation on 5/23/24. The applicant will contact LPA Hansen when the items listed above are complete: LPA will schedule another pre-licensing continued inspection to reinspect as needed. The applicant may contact the LPA at the contact number provided if there are any questions to the above information.the state’s words, verbatim · CDSS document, Jun 5, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Shannan Hansen, conducted a pre-licensing inspection,on 5/23/24 at approximately 8:30AM, and met with applicant Bana Solomon, who will also be the facility's Administrator. RCFE Administrator Certificate #6063962740 expires 8/12/2024. Facility is fire cleared for six(6) non-ambulatory, which includes one(1) bedridden, effective 3/19/24. Applicant has an approved dementia plan of operation. Applicant has submitted an infection control plan for the home as required. Facility is one story with 7 bedrooms, 3 bathrooms, staff breakroom in garage, kitchen/dining room, living room, and a backyard deck. There are two fire extinguishers, inspected and tagged as required 4/9/24. Facilities eleven (11) smoke alarms were working appropriately during the inspection, some are duel carbon monoxide detectors. All exits were unobstructed during the inspection. All exit doors had auditory alarms for use once the home is operating; All exit auditory alarms were working appropriately during the inspection. Backyard gate is self latching and opened appropriately. There are ramps on both sides of the front of the home leading up to the front door for use as needed. All bathrooms had grab bars as required, and non-slip flooring in showers for resident use. The hallways had night lights for resident use. The facility had appropriate furnishings for resident use. Facility has all necessary and required utilities on and operating appropriately. All kitchen appliances were working appropriately. The kitchen has the stove/range knobs covered so they are inaccessible to future residents in care. There is a locking cabinet in the kitchen to store the knives and other sharps. The kitchen also has a cabinet under the sink that can be locked for toxins/cleaners to ensure they are inaccessible to future residents in care. Other cleaners/toxins will be stored in the garage and inaccessible to residents in care. Hot water was checked at 115, 118.4 & 120.5 degrees F. Continued on LIC809C... Administrator informed there is 2 water heaters and has turned one down. There is a key code lock and key access to a small storage closet in the hallway that will be used to secure medications and keep them locked and inaccessible to future residents. There is also a key code lock and key access to Kitchen door to garage containing laundry room, office where records will be kept and with other supplies such as cleaners/toxins, inaccessible to residents in care. Applicant completed Component III Orientation during the pre-licensing inspection. Applicant's front door ramps needs the wood railings to be replaced due to unstable/shaky & west side ramp has uneven pavement Administrator tripped over during inspection that will need to be fixed; Applicant has an appointment set up for this to be done. Backyard deck to have latching fence to keep residents in care from entering back field with holes, etc.. East side exit door to have key code lock to prevent residents from exiting as there is a cement step outside of door that residents could fall off of. Applicant will finish putting things together and up as discussed such as Posting of all required documents. The applicant will contact LPA Hansen when the items listed above are complete; LPA will schedule another pre-licensing continued inspection to reinspect as needed. The applicant may contact the LPA at the contact number provided if there are any questions to the above information.the state’s words, verbatim · CDSS document, May 23, 2024