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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:00:21 PM


Document Has Been Signed on 08/02/2022 12:00 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BELLO GARDENS ASSISTED LIVINGFACILITY NUMBER:
216803239
ADMINISTRATOR:VIERRA, CHARLEENFACILITY TYPE:
740
ADDRESS:46 MARIPOSA AVENUETELEPHONE:
(415) 453-3494
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY:25CENSUS: 20DATE:
08/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Charleen Vierra Administrator TIME COMPLETED:
12:01 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator, Charleen Vierra.

LPA is following up regarding a self-reported Incident Report received on 7/15/2022 regarding three residents who were being isolated due to Covid-19. Report revealed that facility staff were using towels and garbage bags wrapped around resident doors in order to contain them. On 7/9/2022 resident, R1 pulled the silent fire alarm prompting a response from the local fire department who observed the towels on the doors, per Special Incident Report.

Facility is being cited today for 87203 Fire Safety violation with an immediate Civil Penalty in the amount of $500. & 87468.1(a)(6) Personal Rights violation


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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 2


Document Has Been Signed on 08/02/2022 12:00 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
CCLD Regional Office, 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: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2022
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
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Based on records obtained and interviews conducted, licensee did not comply by restricting ability of residents to exit, which poses an immediate health, safety or personal rights risk to persons in care. **Immediate Civil Penalty assessed in the amount of $500.
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Additionally, facility will conduct an in-service for all staff regarding the regulation and submit signed & dated log for all staff to be submitted no later than 8/9/2022.
**Immediate Civil Penalty assessed in the amount of $500.
Type A
08/03/2022
Section Cited

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87468.1 (a)(6) Personal Rights of Residents in All Facilities (a) Residents in all RCFE shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by:
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Based on LPA record review & interviews R1 & residents, movements were restricted to the facility. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Licensee agrees to obtain training from an outside source for all staff on the topic of residents’ personal rights and to ensure that residents needs are being met, sign in log with dates and name of training to be submitted by 8/9/22.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2