216803239-3-13-2025-21-AS-BMOS-DF3UJQ-20250324153753

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803239
Report Date: 03/13/2025
Date Signed: 03/13/2025 01:54:05 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/31/2024 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20241231090356

FACILITY NAME:	BELLO GARDENS ASSISTED LIVING		FACILITY NUMBER:	216803239
ADMINISTRATOR:	TWEED,RACHEL		FACILITY TYPE:	740
ADDRESS:	46 MARIPOSA AVENUE		TELEPHONE:	(415) 453-3494
CITY:	SAN ANSELMO	STATE: CA	ZIP CODE:	94960
CAPACITY:	25	CENSUS: 23	DATE:	03/13/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Frank Nola, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff hit resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation. LPA met with Administrator, Frank Nola.
Complaint alleges a staff hit a resident in care. On 12/31/2024 the department received an (SOC 341) unusual incident report indicating on the morning of 12/28/2024 a resident (R1) had been struck from behind by a staff (S1), resulting in difficulty standing or walking. On 1/2/2025 Community Care Licensing (CCL) received a self-reported incident report from the facility indicating they were informed of an alleged incident on said date at approximately 7:45am after breakfast in the dining room, where other residents and staff were. R1 was returning to their room upstairs, while passing S1, R1 made a derogatory statement to S1 at which time it is alleged S1 started beating with fists on R1. There were no witnesses and alleged incident was not reported until the following day to staff, at which point S2 investigate/assessed R1 finding no injuries noted. Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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-20241231090356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/13/2025

NARRATIVE

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Continued from LIC9099

Marin Central Police Authority report of 12/30/2024, Suspended. Interviews conducted by officers at the scene found that resident (R1) did not show any discoloration indicating any bruising on area. LPA Interviews with 3 staff, informed they have never observed S1 act aggressive and or towards any resident. Interview with R1 indicated they were beaten on with fists although when they went to the physician’s the following day there was no bruising. Physician’s report of 12/31/2024 does not indicate R1 was assaulted. Based on the Departments investigation, Interviews conducted and documents obtained, allegation staff hit a resident in care is Unsubstantiated.

Although the allegation may be true, based upon the review of documents and statements provided, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the complaint is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC9099 (FAS) - (06/04)

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