216803239-10-14-2022-21-AS-SHAN-CK7UQZ-20221014154757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 10/14/2022
Date Signed: 10/14/2022 03:48:10 PM

Document Has Been Signed on 10/14/2022 03:48 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 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: 20	DATE:	10/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Charleen Vierra - Administrator		TIME COMPLETED:	03:55 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	License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by Staff Walter Paredes. Staff contacted Administrator Charleen Vierra who arrived during the inspection. There is a total of 20 residents with 6 residents on Hospice and 13 residents with Dementia. LPA toured the facility on 10/14/2022 at 10:45AM with staff Walter, Chef, Aide. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 6/21/2022 at the time of the visit. Facility smoke detectors are hard wired and sound directly to Stanley Security which notifies Fire and Police Departments. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 8/31/2022. LPA observed Carbon monoxide detectors that were found to be operational during the visit. There is a backup generator that powers many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured 106.7, 109.2, 113.1, 113.5, 118, & 122.7 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in resident’s bathrooms while touring facility. (see LIC 809D). Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Food is available for residents any time of the day. There is a daily activity schedule for residents: scrabble, live music, balloon basketball, & salsa. Toxins are stored in a locked housekeeping closet and under the kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Continue to LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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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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
	VISIT DATE: 10/14/2022

NARRATIVE

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Infection Control:
Facility has submitted a mitigation program plan that was approved. Posters have been placed at facility. Facility has PPE supply stored in the upstairs closet and downstairs in the kitchen and administrator’s office. Residents’ medications are centrally stored and locked in the kitchen. Facility has a 30-day supply of medication for residents. Staff had required PPE training and N95 Fit Testing.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is correct and updated at this time; no need to change any of the information. Disaster Drills have been conducted quarterly with the last one being conducted on 8/16/2022. LPA advised facility to contact Marin County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of current CPR & 1^st Aid certification for staff.
Administrator Certificate is for Charleen Vierra 6053696740 Exp. 10/2/2023
All staff have received COVID booster vaccinations.

Licensee has not submitted the infection control plan. The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agrees to submit the Infection Control Plan by December 14, 2022”. LPA is issuing a Technical Assistance (see LIC 9102TA).

While at facility LPA was provided a list of staff currently working. Staff (S1) was identified by LPA as not having fingerprint clearance and has worked at facility since 9/3/2022.

Immediate Civil Penalties are being assessed in the amount of $500 due to staff S1 not having background check clearance and not being associated to the facility.

*****Total Civil Penalties issued today in the amount of $500.00

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.

Continue on LIC 809-C2

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2022 03:48 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: 10/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

This requirement is not met as evidenced by: Hot water temperature in 1 of facilities residents bathroom faucets messured 122.7 degrees F. falling out of Title 22 acceptable regulation of 105 degrees F. and 120 degrees F.
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee failed to maintain hot water temperature between 105 & 120 F in 1 of 6 resident's bathrooms which poses an immediate Health, Safety risk for residents in care. LPA toured the facility w/ administrator. and observed that 1 of the 6 hot water temperatures was 122.7 degrees F.
	POC Due Date: 10/17/2022
	Plan of Correction
1 2 3 4	Licensee to ensure water temperature is maintained within regulation - 105 TO 120 degrees F. Administrator to submit pluming inspection from this weekend by EOB 10/17/2022. Facility to begin monitoring for the next 7 days. Admin to submit a 7 day log taken from the resident's bathrooms to CCL by 10/24/2022.

Type A

Section Cited

CCR

87355(e)(1)

This requirement is not met as evidenced by :All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
	Deficient Practice Statement
1 2 3 4	Based on observation Administrator didn't comply w/section cited above in 1 out of 5 staff did not have the proper fingerprint clearance and was not associated.
	POC Due Date: 10/17/2022
	Plan of Correction
1 2 3 4	Administrator agrees to send in written plan of correction that they understand all staff must be fingerprint cleared and associated prior to working in the facility. POC due date of 10/17/2022. Due to Administrators failute to have S1 fingerprint cleared and associated to the facility Civil Penalties are being issued today in the amount of $500.00.

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 10/14/2022

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LIC 809-C 2

Appeal of Rights Given

LPA Hansen is requesting Licensee to update and submit the following documents by 10/28/2021:

Copy of Annual Sprinkler Inspection
LIC 308 Designation of Responsibility
LIC 309 Administrative Organization
Articles of Corporation
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of current Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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