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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201373
Report Date:
10/16/2024
Date Signed:
10/16/2024 02:00:10 PM
Document Has Been Signed on
10/16/2024 02:00 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 LIVING
FACILITY NUMBER:
019201373
ADMINISTRATOR/
DIRECTOR:
SUMABAT, JEFF
FACILITY TYPE:
740
ADDRESS:
22400 2ND STREET
TELEPHONE:
(760) 547-2863
CITY:
HAYWARD
STATE:
CA
ZIP CODE:
94541
CAPACITY:
175
CENSUS:
0
DATE:
10/16/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:32 PM
MET WITH:
Jeff Sumbat, Executive Director
TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Jill Clancy-Czuleger and David Doidge conducted an announced Component III Training. Component III was attended by Jeff Sumbat (Executive Director) and Regional Vic President of Operations (VPO ) Zach Butcher.
LPA Clancy-Czuleger presented the training via Power Point presentation and had a discussion with the ED and .
Exit interview conducted and copy of this report provided at the conclusion of the training
SUPERVISORS NAME
:
Harpreet Humpal
LICENSING EVALUATOR NAME
:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/16/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2024
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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