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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 10/07/2021
Date Signed: 10/07/2021 02:22:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BELLO GARDENS ASSISTED LIVINGFACILITY NUMBER:
216803239
ADMINISTRATOR:HINTON, NEYSAFACILITY TYPE:
740
ADDRESS:46 MARIPOSA AVENUETELEPHONE:
(415) 453-3494
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY:25CENSUS: 22DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Neysa HintonTIME COMPLETED:
02:25 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by Walter Paredes, Food Services. Staff contacted Administrator who arrived during the inspection. There is a total of 22 residents. There is 2 residents currently on Hospice and some residents with Dementia.

LPA arrived at the facility and had temperature checked and logged. All staff are temperature checked and logged each shift and wear masks. LPA toured the facility on 10/07/2021 at 12:15 PM with Walter Paredes, Chef, Aide; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 7/28/21 at the time of the visit. Facility smoke detectors are hard wired and sound directly to Stanley Security which notifies Fire and Police Departments. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 10/06/2021 LPA observed Carbon monoxide detectors that were found to be operational during the visit. There is a backup generator that powers many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 112.2 degrees F and 105.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in of resident’s bathrooms while touring facility.

Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen are on 10/7/2021. Food is available for residents any time of the day. There is a daily activity schedule for residents. Residents were playing balloon volleyball at time of visit and bingo was up next “stated another resident”.

Continue to LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: BELLO GARDENS ASSISTED LIVING
FACILITY NUMBER: 216803239
VISIT DATE: 10/07/2021
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Toxins are stored in a locked housekeeping closet and under the kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing.

Infection Control:
Facility has submitted a mitigation program plan that was approved 1/28/2021. Posters have been placed at facility. Facility has PPE supply stored in the upstairs and closet and downstairs in the kitchen and administrator’s office. Residents’ medications are centrally stored and locked. Facility has a 30-day supply of medication for residents. Residents do not wear masks inside the facility. Staff had required PPE training and N95 Fit Testing.

LPA was presented with proof of CPR & 1st Aid certification for staff. Neysa Hinton, Administrator CPR/1st Aid expires on 5/21/2022.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have been conducted quarterly with the last one being conducted on 9/20/2021. LPA advised facility to contact Marin County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.




LPA Hansen is requesting Licensee to update and submit the following documents by 10/21/2021:

Copy of Annual Sprinkler Inspection
LIC 308 Designation of Responsibility
LIC 309 Administrative Organization
Articles of Corporation
LIC 500 Personnel Summary
LIC 9020 Register of Facility Client’s/Resident’s

There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC809 (FAS) - (06/04)
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