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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 10/27/2022
Date Signed: 10/27/2022 11:25:58 AM


Document Has Been Signed on 10/27/2022 11:25 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 LIVINGFACILITY NUMBER:
216803239
ADMINISTRATOR:VIERRA, CHARLEENFACILITY TYPE:
740
ADDRESS:46 MARIPOSA AVENUETELEPHONE:
(415) 453-3494
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY:25CENSUS: 19DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Charleen Vierra - AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a case management inspection and was greeted by staff Walter. Administrator Charleen Vierra arrived 20 minutes later. The purpose of this case management inspection is to follow up on corrections requested at facilities annual inspection.

LPA toured the facility and grounds with staff Walter and observed new waterheater, and tested water temperature,which was within Title 22 Regulations of 105 - 120 degrees F. LPA observed new flooring in hallway and backyard had been cleaned up of any dangerous items that could cause injuries to residents in care.

LPA reminded Administrator, documents requested at annual inspection are due.

No deficiencies cited during today’s inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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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