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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 02/14/2023
Date Signed: 02/14/2023 11:32:43 AM


Document Has Been Signed on 02/14/2023 11:32 AM - 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:
02/14/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Owner, Mark Bello, Executive Director, Neysa Hinton, and Administrator Charleen Vierra.TIME COMPLETED:
10:40 AM
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An informal meeting was conducted today via Microsoft Teams, present in the meeting were, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst, Shannan Hansen, Owner, Mark Bello, Executive Director, Neysa Hinton, and Administrator Charleen Vierra.

The purpose of the informal office meeting was to discuss concerns that have been identified by the department.

The following was discussed during the office meeting:

* Timely Medical - Related to complaint investigated resulted in substantiated findings, reference complaint 21-AS-20221028104235.

* AWOL policy - related to recent incident of AWOL and citation issued due to following facilities elopement policy, reference case management LIC 809 on 1/26/2023 .

* Eviction regulation - LPA Hansen provided eviction regulations 87224 on 1/20/2023 .



Participants in this meeting have been informed that the informal meeting is part of the departments administrative process, further non compliance may result in a non compliance plan.

No citations issued

Original signature on file. A copy of this report was emailed to Licensee.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
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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