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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201373
Report Date: 03/03/2026
Date Signed: 03/03/2026 04:13:06 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
01/28/2026 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20260128154841
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: 140DATE:
03/03/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jeff Jhunell Sumabat, Excutive Director TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Licensee does not ensure that facility is kept in good repair.
INVESTIGATION FINDINGS:
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On this day, 3/3/26 at 12:00 pm, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to investigate the above allegation and to deliver findings. LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for the visit.

It was alleged that the Licensee does not ensure that the facility is kept in good repair. On 1/30/2026, LPA K. Nguyen observed that the door in the memory care unit on the second floor is not working properly. LPA tested the delayed egress door above the elevator and inside the memory care unit and observed that the delayed egress door does not open after 15 seconds. On 1/30/26, during an interview with S2, S2 stated, “That door does not open without the keypad code, and when held for 15 second nothing happened”. S1 stated "the 15-second hold was never installed on the door".

Report continue on LIC 9099c...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
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 6
Control Number 15-AS-20260128154841
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: 03/03/2026
NARRATIVE
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Based on the information obtained, the preponderance of evidence is met; therefore, 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 within 12 month period may result in civil penalty.

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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20260128154841
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: 03/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2026
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidence by:
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Facility has agreed to submit proof that all delayed egress doors will be in operating condition by POC date.
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Based on observation and interview, licensee did not comply with the section cited above by having inoperable delayed egress door which poses a potential health and safety risk to the residents 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
01/28/2026 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20260128154841

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:
03/03/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jeff Jhunell Sumabat, Excutive Director TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Licensee does not ensure that resident's have freedom of movement while in care.
Licensee does not ensure that resident's are provided a healthful environment while in care.
Licensee does not ensure that facility is kept in a sanitary condition.
Licensee does not ensure that there is adequate staff available for food services cleanup.
INVESTIGATION FINDINGS:
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On this day, 3/3/26 at 12:00 pm, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to investigate the above allegation and to deliver findings. LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for the visit.

Allegation: Licensee does not ensure that residents have freedom of movement while in care – Unsubstantiated

It was alleged that the licensee does not ensure that residents have freedom of movement while in care. During the investigation, LPA conducted interviews with 16 residents, 10 staff, and reviewed facility policies and records relevant to resident rights.

Report continued on LIC 9099c...

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
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 6
Control Number 15-AS-20260128154841
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: 03/03/2026
NARRATIVE
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LPA Interviews with 16 residents did not reveal any instances in which their freedom of movement was restricted inappropriately. 16 out of 16 Residents stated they were able to move freely within the facility and access common areas consistent with their individual care plans.

Allegation: Licensee does not ensure that residents are provided a healthful environment while in care - Unsubstantiated

It was alleged that the licensee does not ensure that residents are provided a healthy environment while in care. During the investigation, LPA conducted interviews with 16 residents, 10 staff, reviewed facility records, and observed a display case with alcohol.

Interviews with 11 residents did not indicate concerns regarding alcohol served at the facility, safety, or overall healthfulness of the environment. Resident 1 through Resident 11 stated, “Every Thursday, the facility has happy hours that offer us alcohol; however, facility staff never tried to sell any alcohol. R1 through R11 stated, “The facility offered alcohol to us; however, they based their decision on our medical records, and those who cannot drink were not offered.” S1, S2, and S3 stated, “We don’t ever charge for that; it was just part of our beverages that we offered”. LPA reviewed facility admission agreements; there was no indication of alcohol charges in the admission agreement.

Allegation: Licensee does not ensure that the facility is kept in a sanitary condition – Unsubstantiated

It was alleged that the licensee does not ensure that the facility is kept in a sanitary condition. Observations made by the LPA on 1/30/26 and 3/3/26 did not reveal unsanitary conditions, including accumulation of trash, odors, pests, or other conditions that would pose health risk to residents. LPA toured a random section of the random Memory Care (MC) apartment (APT) and Assisted Living (AL) apartments. LPA toured the MC and AL apartment, including but not limited to APT: 201, 202, 215, 225, 217, 222, 225, 505, 506, 502, 501, 316, and 133. All APTs are clean and sanitary. There is no odor in any of the apartments.

Report continued on LIC 9099c1

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20260128154841
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: 03/03/2026
NARRATIVE
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LPA conducted 16 random selections of residents. 16 out of 16 residents interviewed did not report concerns regarding sanitation or cleanliness of the facility. LPA conducted 10 Staff interview and 10 out of 10 stated that routine cleaning schedules and sanitation practices are in place and followed to maintain a clean environment.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.




Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6