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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:32:15 PM


Document Has Been Signed on 01/20/2023 12:32 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BELLO GARDENS ASSISTED LIVINGFACILITY NUMBER:
216803239
ADMINISTRATOR:VIERRA, CHARLEENFACILITY TYPE:
740
ADDRESS:46 MARIPOSA AVENUETELEPHONE:
(415) 453-3494
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY:25CENSUS: 19DATE:
01/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Charleen Vierra, AdministratorTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a case management inspection and met with Administrator Charleen Vierra. The purpose of this case management inspection is to follow up on a phone call LPA received on 12/30/2022 and Incident report submitted to community care licensing (CCL).

LPA is following up regarding a self-reported Incident Report received on 1/5/2023 regarding resident, R1 who on 12/30/2022 while getting up fell against a wall and then fell down hitting the back of head. R1 was taken to the hospital. On 12/30/2022 LPA had phone conversation with Administrator who was not wanting R1 to be discharged back to facility. During today’s visit LPA provided regulations on evictions. LPA advised Administrator proper eviction procedures to be in compliance with regulation provided.

Regulation 87224 Eviction Procedures provided to Administrator

There were no deficiencies cited during today’s visit.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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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