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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200139
Report Date: 01/24/2025
Date Signed: 01/24/2025 05:41:09 PM

Document Has Been Signed on 01/24/2025 05:41 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:NEW BELLEVUE MANORFACILITY NUMBER:
019200139
ADMINISTRATOR/
DIRECTOR:		SHIELHA MUNIZFACILITY TYPE:
735
ADDRESS:3056 RANDALL WAYTELEPHONE:
(510) 538-3053
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 12CENSUS: DATE:
01/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Aileen Fajardo/StaffTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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At 2:00 pm on this day, 1/24/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) and SOC341 submitted by Juliana Taburaza, licensee, on 1/06/25. LPA met with staff, Aileen Fajardo, Julita Shoban and Estelita Tubangui. LPA called and spoke over the phone with licensee, and informed the reason for visit. Licensee arrived at around 3:00 pm.

UIR and SOC341 indicated that on 1/03/25, two deputy sheriffs arrived to the facility and interviewed resident (R1), the staff and another resident due to the report of alleged abuse. On that same day, the licensee indicated that they received an email from R1's family member (FM) informing R1's care team; carbon copied on the email was another facility director. FM indicated that FM received a call from a deputy officer (DO) regarding a report about the alleged victim (R1) and alleged abuse that a male employee of the facility kissed and touched R1. SIR further indicated that FM stated another incident regarding a past male employee who was the administrator hurt R1. This incident was allegedly reported to the licensee but the licensee dismissed it because the administrator no longer works at the facility. There were complaints investigated by the Department.

LPA discussed with the licensee the above SIR. LPA further discussed the misinformation on the SIR pertaining to the complaint particularly about the allegations investigated by the Department indicating that LPA focused on the AWOL behavior. Licensee to correct the SIR and resubmit by Monday, 1/27/25.



.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139
VISIT DATE: 01/24/2025
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LPA reviewed R1's record and conducted interviews. LPA obtained copies of including but not limited to the following documents: LIC601 Identification and Emergency Contact Information; Face Sheet; LIC602A Physician's Report; Appraisal; LIC625 Appraisal/Needs and Services Plan; licensee's documentation of interview

No deficiency cited on day. Additional information is still to be obtained, and LPA may come back for another case management visit.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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