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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:02:08 PM


Document Has Been Signed on 01/26/2023 03:02 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:
01/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Charleen Vierra - AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator, Charleen Vierra.

LPA is following up regarding a self reported Incident Report received on 1/24/2023 that occurred on 1/17/2023. At approximately 8:20 am R1 AWOLed from facility, could not be located and later was found by individual after falling. Individual called 911 and R1 was taken to hospital.

Based on LPA's interviews R1 was AWOLed for approximately 2 hours. Per facility policy, Law Enforcement authorities are to be notified of elopement within 30 minutes, should resident not be located. LPA received conflicting statements from interviews and incident report submitted. Facility did not follow personnel requirements and or their plan of operations for elopement (see LIC 809-D).

LPA requested documents to be submitted to CCL.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/26/2023 03:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 216803239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited

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87411(a) Personnel Requirements – General:

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
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Administrator to ensure that all staff are trained in dementia care-specifically elopement procedures and policy including response to auditory alarms and contacting Law Enforcement. Administrator agreed to provide scheduled dates for all staff trainings to CCL by POC due date.
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This requirement has not been met as evidenced by: Based on records reviewed and interviews conducted, facility staff did not respond to residents elopement in an appropriate amount of time and or follow facilities Plan of Operation by contacting Law Enforcement. Records reviewed indicated that resident was a wanderer w/ dementia, not allowed to leave facility unatended. Interviews stated R1 AWOLed for aprox 2 hrs before outside individual contacted 911. Facility protocol is to contact law enforcement within 30 min.This poses an immediate risk to the health and safety of 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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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