216803239-10-26-2026-21-AS-DALO-DZ8SQB-20261026140428

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 10/26/2026
Date Signed: 10/26/2026 02:06:20 PM

Document Has Been Signed on 10/26/2026 02:06 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:	NOLA,FRANK		FACILITY TYPE:	740
ADDRESS:	46 MARIPOSA AVENUE		TELEPHONE:	(415) 453-3494
CITY:	SAN ANSELMO	STATE: CA	ZIP CODE:	94960
CAPACITY: 25		CENSUS: 23	DATE:	10/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Vanessa Fernandez- Director of Care		TIME VISIT/ INSPECTION COMPLETED:	02:20 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	Licensing Program Analyst (LPA), Alviso, conducted a Required - 1 Year Inspection, on 10/26/26, and met with Vanessa Fernandez, Director of Care (DOC). Fire clearance approved for twenty-five (25), of which eleven (11) may be non-ambulatory on the first floor only. Currently there are twenty-three (23) residents in care; There are four (4) residents on hospice services. Hospice care waiver approved for five (5) residents. Facility has a required infection control plan. Facility has a required emergency disaster plan. LPA reviewed six (6) resident files, including medication records and observed storage of medications. All files were complete. LPA reviewed five (5) staff files. All staff have required criminal record clearance. LPA reviewed staff training. All care staff have first aid certification and CPR certification. Per LPA's review of required quarterly emergency drills, there was no record of drills being of different scenarios, and drills covering all shifts. LPA provided a technical violation, HSC 1569.695(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. 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. LPA toured the facility. Hot water was checked at 118.9 degrees Fahrenheit. All exits were free and clear of obstruction. There was sufficient lighting in common areas, hallways, bathrooms, and resident rooms. All fire extinguishers were serviced and tagged. Continued on LIC809C...

Bethany Moellers
Dina Alviso
	DATE: 10/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2026

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 3

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 3

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: 10/26/2026

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

Both stairwells had required evacuation chairs. All medications were locked up and inaccessible to residents in care. All cleaners/disinfectants were locked and inaccessible to residents in care.Bathrooms were clean and orderly during the inspection; Bathrooms had grab bars, and mats/non-slip flooring for resident use. LPA observed a sufficient supply of food, frozen meats, vegetables, fruit, canned items, drinks, and other miscellaneous food items. The outside backyard area has a sitting area with tables and shade for residents wanting to sit outside or take a walk around the courtyard. Walkways were clear of obstruction. The facility was having a new heater unit installed during today's inspection. Both facility stairs in the building will have new carpet installed within two weeks, per Vanessa, DOC.

LPA is requesting the following documents be updated and submitted by 11/26/26:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610-Emergency Disaster Plan (9 pages)- Review & update as required, sign & date, submit a copy
LIC400- Affidavit of Client Cash Resources (all facilities complete the form)
Copy of Bond if handling cash, Amount per LIC400
Copy of Current Liability Insurance
Infection Control Plan- Review & update as required, sign & date, submit a copy
Poster of Residents
Copy of current Administrator Certificate

There are no deficiencies cited today.
Exit interview held with Vanessa Fernandez, Director of Care.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2026

LIC809 (FAS) - (06/04)

Page: 3 of 3