216803239-10-22-2021-21-AS-KMOA-C8FTXX-20211104150750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803239
Report Date: 10/22/2021
Date Signed: 10/22/2021 04:13:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2021 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20210805114652

FACILITY NAME:	BELLO GARDENS ASSISTED LIVING		FACILITY NUMBER:	216803239
ADMINISTRATOR:	HINTON, NEYSA		FACILITY TYPE:	740
ADDRESS:	46 MARIPOSA AVENUE		TELEPHONE:	(415) 453-3494
CITY:	SAN ANSELMO	STATE: CA	ZIP CODE:	94960
CAPACITY:	25	CENSUS: 22	DATE:	10/22/2021
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Supervising Med Tech Josefa Mancinas		TIME COMPLETED:	10:07 AM

ALLEGATION(S):

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Facility staff are violating residents' rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of a subsequent complaint investigation resulting in delivering findings of the above allegations. LPA met with Supervising Med Technician of the day Josefa Mancinas as Administrator Neysa Hinton was not in but authorized by phone for staff to sign for her.

During the investigation LPA reviewed records, made observations at the facility and conducted interviews.

Facility staff are violating residents’ rights. –LPA conducted interviews with staff, outside sources, and residents during investigation, along with record reviews and observations. Complaint alleges facility did not respond to reports of abuse by staff to residents for over a year. Allegations include an incident where a resident was cut on the hand during a struggle with staff.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210805114652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/22/2021

NARRATIVE

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Due to conflicting statements and no documentation that incidents occurred LPA was unable to corroborate the above allegations, therefore the allegation is unsubstantiated

This Department has investigated this complaint and determined that although the allegations Facility staff are violating residents’ rights may be true or valid, there is not a preponderance of evidence to prove the alleged violation did or did not, occur. Therefore, the allegation is deemed UNSUBSTANTIATED.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

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