<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
216803239
Report Date:
05/04/2022
Date Signed:
05/09/2022 11:42:23 AM
Document Has Been Signed on
05/09/2022 11:42 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:
05/04/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
03:07 PM
MET WITH:
Administrator Charleen Vierra
TIME COMPLETED:
04:25 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
*****amended report.
LIC809 generated in error under this facility.
SUPERVISORS NAME
:
Bethany Moellers
LICENSING EVALUATOR NAME
:
Shannan Hansen
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)
Page:
1
of
1