216803239-12-30-2024-21-AS-JFLO-DCG5K3-20241230190051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 12/30/2024
Date Signed: 12/30/2024 07:01:09 PM

Document Has Been Signed on 12/30/2024 07:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BELLO GARDENS ASSISTED LIVING		FACILITY NUMBER:	216803239
ADMINISTRATOR/ DIRECTOR:	TWEED,RACHEL		FACILITY TYPE:	740
ADDRESS:	46 MARIPOSA AVENUE		TELEPHONE:	(415) 453-3494
CITY:	SAN ANSELMO	STATE: CA	ZIP CODE:	94960
CAPACITY: 25	TOTAL ENROLLED CHILDREN: 0	CENSUS: 19	DATE:	12/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Frank Nola, DRP		TIME VISIT/ INSPECTION COMPLETED:	07:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:45 AM, Licensing Program Analysts (LPAs) Julie Florio and Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and were greeted by Staff. Designated Responsible Party (DRP), Frank Nola, was contacted and arrived at approximately 10:20 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with 19 residents in care. Facility has a Dementia Care Plan, is approved for 11 non-ambulatory residents, bedridden residents on first floor only, and has a Hospice waiver for 5. Facility currently has one (1) Hospice resident in care. At approximately 10:40 AM, LPAs initiated a tour of the facility with DRP and observed the following: Facility is a two story converted convent, was a comfortable temperature, and passageways were free from obstructions. LPAs observed an evacuation chair at each stairwell for emergency prepairdness. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPAs observed a menu posted throughout the facility, and facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency Food and water supply. However, LPAs observed at least three instances of expired food and several instances of unlabeled opened or unsealed food items throughout facility freezers and refrigerators, (see LIC809D). Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPAs observed two (2) locked sheds in the backyard which LPAs inspected and observed the contents to consist of PPE supplies, extra resident care equipment, holiday decorations, chemicals and tools. Continued on LIC809-C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

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 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BELLO GARDENS ASSISTED LIVING	FACILITY NUMBER: 216803239
	VISIT DATE: 12/30/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809C...

LPAs observed an activity schedule and residents attending a live music session in the facility's activity room during inspection. LPAs observed games, activities, crafts, movies, musical instruments and more for residents in care. Facility has internet access and provides an internet access device for resident use. Facility has a telephone which was tested during inspection.

Facility's fire extinguishers were observed charged and were last serviced 06/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Centralized Fire system is inspected annually. Facility conducts bi-yearly disaster drills. However, Facility was unable to provide proof of completion on for any drills this year, (see LIC809D). Additionally, LPAs advised DRP that drills shall be conducted on a quarterly basis to bring the facility into compliance with regulation. LPAs observed the facility's infection control plan, first aid kit, PPE, and emergency supplies. LPAs reviewed facility's emergency disaster plan last updated 10/2024.

At approximately 12:15 PM, LPAs conducted file review. Six (6) staff files and six (6) resident files were reviewed. All staff files reviewed have all of the required paperwork except Staff 1 (S1) was missing proof of negative TB results; S1, Staff 2 (S2), and Staff 3 (S3) were missing proof of at least 20 hours of required initial training; and S1, S2, S3, and Staff 4 (S4) were missing proof of the required 16 hours of medication training shadowing, (see LIC809Ds). All staff had proof of CPR and First Aid training. Six (6) of six (6) resident files reviewed contained the required documentation per regulation. However, Resident 1 (R1) was missing proof of negative TB results and a signed admissions agreement; Resident 2 (R2) was missing a consent for emergency medical treatment and a signed care plan; and Resident 3 (R3) and Resident 4 (R4) were both missing signed care plans as well, (see LIC809Ds).

DRP states residents' families coordinate residents' medical and dental appointments and transportation to and from visits. Medications were reviewed and observed managed and maintained within regulation. However, LPAs observed at least one (1) medication not recorded into the resident's centrally stored medication record and other instances of medications being improperly recorded, (see LIC809D).

continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

Page: 2 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BELLO GARDENS ASSISTED LIVING	FACILITY NUMBER: 216803239
	VISIT DATE: 12/30/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

continued from LIC809C...

Required Change of Administrator Documents:

LIC 308 (Designation of Facility Responsibility)
Active and Current Administrator Certificate
First Aid Certificate
LIC 500 (Personnel Report)
LIC 501 (Personnel Record)
LIC 503 (Health Screening Report - personnel)
Proof of Negative TB test
LIC 9182 (Criminal Record Exemption Transfer Request)
LIC 508 (Criminal Record Statement)
Copy of Driver's License or Passport that is not expired
Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

Proof of Liability Insurance (updated)
Proof of property ownership

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted with DRP and Appeal rights were given. Signature on form confirms receipt.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 10

Document Has Been Signed on 12/30/2024 07:01 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
SANTA ROSA RO, 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: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Infection Control Requirements

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring that bathrooms and bedrooms were clean and sanitary. LPAs observed three quarter sized reddish brown feces smear marks on the floor under the toilet in one of the facility's communal bathrooms. Additionally, LPAs smelled urine in resident room where the floor felt sticky upon entry and a bedside commode was observed with urine in it. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/17/2025
	Plan of Correction
1 2 3 4	DRP to submit self certification that facility has been brought into compliance and will remain in compliance with regulation moving forward to CCL by POC due date 1/17/2024.

Section Cited

Personal Accommodations and Services

(c) Individual privacy shall be provided in all toilet, bath and shower areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one instance where a residents bedroom opened up onto a communal bathroom, which poses a potential personal rights risk to persons in care.
	POC Due Date: 01/17/2025
	Plan of Correction
1 2 3 4	DRP to submit picture proof that the door between bedroom #11 and the connecting communal bathroom is permanently locked from both sides to maintain resident privacy and remain in compliance with residents personal rights to CCL by POC due 1/17/2024.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

Page: 4 of 10

Document Has Been Signed on 12/30/2024 07:01 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
SANTA ROSA RO, 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: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in ensuring that facility has a complete and accurate record for all staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	DRP to submit self certification that all records have been brought into compliance with regulation to CCL by POC due date 1/31/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

Page: 5 of 10

Document Has Been Signed on 12/30/2024 07:01 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
SANTA ROSA RO, 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: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in ensuring that all staff have the required initial training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	DRP to submit proof of completion of all required initial training for staff to CCL by POC due date 1/31/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

Page: 6 of 10

Document Has Been Signed on 12/30/2024 07:01 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
SANTA ROSA RO, 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: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in ensuring that all staff who assist residents with medication administration have proof of all the required initial medication administration training completed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	DRP to submit proof of completion of all required initial medication administration training for required staff to CCL by POC due date 1/31/2025.

Section Cited

General Food Service Requirements

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in at least three instances of observed expired food and several instances of unlabeled opened or unsealed food items throughout facility freezers and refrigerators which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	DRP to submit self citification that all food has been inspected and facility has been brought into compliance with regulation. Additionally, DRP to submit proof of staff training reviewing proper food labeling and storage to CCL by POC due date 1/31/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

Page: 7 of 10

Document Has Been Signed on 12/30/2024 07:01 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
SANTA ROSA RO, 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: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in ensuring that facility maintains proof of disaster drills completed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	DRP to submit proof of a required quarterly disaster drill completed on each shift to CCL by POC due date 1/31/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

Page: 8 of 10