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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201373
Report Date: 07/22/2026
Date Signed: 07/22/2026 04:37:51 PM

Document Has Been Signed on 07/22/2026 04:37 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BELLARA SENIOR LIVINGFACILITY NUMBER:
019201373
ADMINISTRATOR/
DIRECTOR:		COLLETTE VALENTINEFACILITY TYPE:
740
ADDRESS:22400 2ND STREETTELEPHONE:
(510) 244-0949
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 175CENSUS: DATE:
07/22/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Jeff Sumabat/Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On this day, July 22, 2026, Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a Priority 1 complaint (Complaint Control # 15-AS-20260721112430). LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for visit. LPA also met with Sr. Generations Program Director (GPD) Joy Quilet.

During review of residents' (R1 and R2) records, LPA observed After Visit Summaries and Physician Communications indicating these residents have fall incidents. R1 had 5 fall incidents from 6/04/26 to 7/20/26, of which 4 of these incidents had passed 7 days and facility did not submit nor LPA received incident reports. R2 had multiple fall incidents from 5/10/26 to 7/17/26, of which 7 had also passed 7 days and facility also did not submit incident reports. LPA also observed these residents Care Plans not updated nor reassessment completed to reflect current care needs. Staff (S1) confirmed no incident reports submitted and that Care Plan not updated.

LPA toured the Memory Care Unit with Joy Quilet. LPA inspected the following including but not limited to common areas, courtyard, dining and activity areas, servery/kitchenette, toilets and ensuite bathrooms. LPA observed the laundry room locked and medication room attended by a med-tech. LPA randomly selected 7 residents' apartments for inspection including the ensuite bathrooms.



.....continued on 809C
Bennett Fong
Alicia Delmundo
DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2026
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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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: BELLARA SENIOR LIVING
FACILITY NUMBER: 019201373
VISIT DATE: 07/22/2026
NARRATIVE
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LPA observed the following during inspection:
-at 2:20 pm, shaver in one of the residents' apartments.
-at 2:40 pm, unlocked wound solution, Desitin rash ointment, foot cream in another resident's apartment and wound cleanser in the ensuite bathroom.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for section # 87309(a) for repeat violation within 12 month period. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies, plan and proof of corrections and civil penalty were discussed with the Executive Director.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2026 04:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/22/2026 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELLARA SENIOR LIVING
FACILITY NUMBER: 019201373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2026
Section Cited
CCR
87309(a)

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87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to resident are in locked storage....
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Staff removed and locked the items.

In addition, Executive Director to in-service the staff and submit copy of training topics with attendees signatures by 7/23/26.

A $250.00 civil penalty is assessed.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above in the following unlocked in Memory Care apartments which posed an immediate risks to persons in care: razor, wound solution and cleanser; foot cream; rash ointment
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Type A
07/23/2026
Section Cited
CCR87463(b)

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87463 Reappraisals
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident..
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Executive Director to have the Care Plan updated and submit copies by 7/23/26.
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.....and to keep the appraisal accurate
-This requirement is not met as evidenced by:
-Based on records review and interview, the licensee did not comply with the section above in not doing reassessments and/or updating the Care Plan for R1 and R2 which posed an immediate risks to the health, safety and/or personal rights risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2026


LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/22/2026 04:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/22/2026 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELLARA SENIOR LIVING
FACILITY NUMBER: 019201373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2026
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports ...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...
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Executive Director to do the following and submit proof by 8/05/26:
1. Submit incident reports.
2. In-service the staff and ensure reports are submitted within Regulations time frame.
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(D) Any incident which threatens the welfare, safety or health of any resident......
-This requirement is not met as evidenced by:
-Based on records review and interview, the licensee did not comply with the section above in not submitting incident reports.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2026


LIC809 (FAS) - (06/04)
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