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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201355
Report Date: 04/02/2024
Date Signed: 04/02/2024 04:42:49 PM

Document Has Been Signed on 04/02/2024 04:42 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BELLO RESIDENTIAL CARE INCFACILITY NUMBER:
019201355
ADMINISTRATOR:IKHARO, AZZIZ ABDULFACILITY TYPE:
735
ADDRESS:1503 VIRGINIA ST.TELEPHONE:
(510) 969-5107
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 6CENSUS: 4DATE:
04/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Deborah LockhartTIME COMPLETED:
05:00 PM
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On 4/2/2024, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a change of ownership prelicensing visit. Upon entry into the facility, the LPA informed Administrator (ADM) Deborah Lockhart of the purpose of the visit.

LPA toured the facility inside out with the ADM. The LPA inspected the kitchen, common areas, bedrooms, bathrooms, and the exterior of the facility. The facility was clean, appropriately furnished, and well lit. More than the 2 days of perishable and 7 days of nonperishable food supplies were available. No body of water was on the facility grounds. Medications are centrally stored. Personnel, client, and facility records stored at facility. Bathrooms and showers were observed to be fully functioning and clean. Carbon monoxide and smoke detectors operational and the fire extinguishers were last serviced on 3/14/2024. First aid kit inspected. Facility has emergency lighting.

Facility passed pre-licensing inspection and Component III training provided for ADM. Final review of application and license to be granted by Central Applications Bureau analyst.

Exit interview conducted and a copy of this report provided via email to the Licensee and ADM.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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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