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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:50:28 PM


Document Has Been Signed on 11/04/2022 12:50 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: 19DATE:
11/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Charleen Vierra - AdministratorTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen had arrived unannounced at facility to open a complaint investigation and was greeted by Staff Elle and Mercedes.

LPA toured facility with staff and observed medications stored in unlocked kitchen cabinet, accessible to residents in care (see LIC 809D).

Facility is being cited per Regulation 87465(h)(2).


Appeal of Rights Given.

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: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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 11/04/2022 12:50 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: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2022
Section Cited

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 87465(h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Based on LPA's observation of medicaiton and unlocked cabinet located in the kitchen, medications are accessible to residents in care. This is an immediate Health and Safety risk to residents in care.
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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: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2