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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
216803239
Report Date:
05/09/2022
Date Signed:
05/09/2022 11:43:12 AM
Document Has Been Signed on
05/09/2022 11:43 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 LIVING
FACILITY NUMBER:
216803239
ADMINISTRATOR:
VIERRA, CHARLEEN
FACILITY TYPE:
740
ADDRESS:
46 MARIPOSA AVENUE
TELEPHONE:
(415) 453-3494
CITY:
SAN ANSELMO
STATE:
CA
ZIP CODE:
94960
CAPACITY:
25
CENSUS:
41
DATE:
05/09/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
11:00 AM
MET WITH:
Administrator Charleen Vierra
TIME COMPLETED:
11:43 AM
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On 5/9/2022 at 11:15 AM LPA Hansen was at this facility to amend a previous report that was generated on 5/4/2022.
No citations issued.
SUPERVISOR'S NAME:
Bethany Moellers
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR NAME:
Shannan Hansen
TELEPHONE:
707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
05/09/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/09/2022
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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