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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201373
Report Date: 10/29/2025
Date Signed: 10/29/2025 06:30:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20251021141652
FACILITY NAME:BELLARA SENIOR LIVINGFACILITY NUMBER:
019201373
ADMINISTRATOR:COLLETTE VALENTINEFACILITY TYPE:
740
ADDRESS:22400 2ND STREETTELEPHONE:
(760) 547-2863
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:175CENSUS: 107DATE:
10/29/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jeff Sumabat/Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff did not report incident to residents' family.
INVESTIGATION FINDINGS:
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On this day, 10/29/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for visit.

It was alleged that the incident between 2 residents (R1 and R2) was not reported to the residents' family. The reporting party stated the residents' family has been trying to contact staff to inquire about the incident that happened on 10/18/25 and no one has called the family back.

LPA reviewed residents records and obtained copies of LIC601 Identification and Emergency Contact information and LIC602A Physician's Reports, staff schedule and residents roster. LPA interviewed residents' family member (FM1), staff (S1 and S2), ED, R1 and R2.

.......continued on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20251021141652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/29/2025
NARRATIVE
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S1 stated that staff, S2, reported to S1 that R1 went down to the front desk on the day of the incident. S1 further stated it was R2's family member, FM2, who sent her text message about the incident and S1 assumed FM2 reported the incident to FM1. S1 stated FM2 indicated that R1 and R2 had a fight because R2's cpap was broken. S1 stated she went to R1 and R2's apartment on 10/19/25 and observed R2's arm has bruise and that R2 reported R1 grabbed R2.

ED stated the incident happened after ED was gone for the day and that S1 and S2 reported the incident to the ED that night.

FM1 stated that R1 and R2 had an incident on 10/18/25, of which R2 punched R1 in the ribs. R2 admitted the physical altercation to FM1 but the incident was not reported by the facility to FM1. FM1 further stated that on the day of incident, R1 went down to the front desk and called FM1 to report the incident. R1 was crying and distraught.

R1 stated having altercation with R2 and that R1 grabbed R2 in the arm. R2 stated pushing R1 during the altercation.

Review of email communications revealed it was FM2 who reached out to ED on 10/19/25 regarding the incident and the email was only responded on 10/21/25.

Based on information gathered, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation may result in civil penalty.

Deficiency and plan and proof of correction were discussed with ED.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20251021141652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2025
Section Cited
CCR
87468.1(a)(9)
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87468.1 Personal Rights of Residents in All Facilities
(a) .......(9) To have communications to the licensee from their representatives answered promptly and appropriately.

-This requirement is not met as evidenced by
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Executive Director will do the following:
and submit proof by 11/12/25:
1. In-service the staff.
2. Ensure proper and timely communication with the residents' families are accorded.
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-Based on document review and interviews, the licensee did not comply with the section above in not reporting the incident to the residents' family and not responding timely.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20251021141652

FACILITY NAME:BELLARA SENIOR LIVINGFACILITY NUMBER:
019201373
ADMINISTRATOR:COLLETTE VALENTINEFACILITY TYPE:
740
ADDRESS:22400 2ND STREETTELEPHONE:
(760) 547-2863
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:175CENSUS: DATE:
10/29/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jeff Sumabat/Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Lack of supervision resulting in resident (R1) being physically abused by another resident (R2).
INVESTIGATION FINDINGS:
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On this day, 10/29/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for visit.

LPA reviewed residents records and obtained copies of LIC601 Identification and Emergency Contact information and LIC602A Physician's Reports, staff schedule and residents roster, Service Agreement. LPA conducted interviews.

LPA interviewed residents' family member (FM1) who stated that on 10/18/2025, R1 called FM1 crying and reported that R2 punched R1 in the ribs. FM1 further stated that R1 went to the front desk to report the incident.

....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20251021141652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/29/2025
NARRATIVE
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S2 confirmed the incident that R1 went to the front desk staff. The front desk staff called her, and she along with the care staff, S3, went to R1 and R2's apartment. R2 broke down and admitted to calling R1 out from drinking alcohol which made R1 got out of control. S2 further stated that they facilitated R2 and told R1 to watch tv. R1 and R2 are not on hourly check and S2 only provides passing of medications to R2.

S1 confirmed the incident; however, S1 was off on the day it happened.

R2 admitted to having an altercation with R1 and that R2 pushed R1 in the ribs. R2 further stated R1 grabbed him in the arm which R1 admitted but R1 does not remember the date it happened.

ED stated a personal companion provided by a third party was placed for R1 back in December 2024 until the family discontinued paying the 3rd party. ED further stated that R1 and R2 are not on hourly check which LPA confirmed upon review of Service Plan.

Based on all the information gathered, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

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

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5