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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 08/24/2022
Date Signed: 08/24/2022 12:02:01 PM


Document Has Been Signed on 08/24/2022 12:02 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: DATE:
08/24/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Owner, Mark Bellos, Executive Director Neysa Hinton, & Administrator Charleen Vierra - Administrator Jolly CarungcongTIME COMPLETED:
11:00 AM
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An informal meeting was conducted today in the Rohnert Park Regional Office via Microsoft Teams due to Covid19 precautions. Present in the meeting were, Licensing Program Manager, Bethany Moellers, Licensing Program Manager, Hope DeBenedetti, Licensing Program Manager, Kimberly Mota, Licensing Program Analyst, Shannan Hansen, Licensing Program Analyst, Caitlynn Felias, and Owner, Mark Bello, Executive Director, Neysa Hinton, Administrator Charleen Vierra, & Administrator, Jolly Carungcong.

The purpose of the informal office meeting was to discuss concerns that have been identified with Fire Safety and Personal Rights violations that occurred on July 9, 2022 at this facility.

The following was discussed during the office meeting:

Fire Safety regulations -

Personal Rights -

Timely POC's - 2 extensions have been given for POC's issued 8/3/2022. LPA confirmed the citation issued on 8/3/2022 for Personal Rights is now cleared based on training submitted.

Areas of concern for Greenwood Assisted Living - 216803761 can been viewed on LIC809 for facility dated 8/24/2022.

No deficiencies cited for this facility.

Original signature on file. A copy of this report was emailed to Licensee.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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