216803899-2-16-2023-21-AS-CFES-CP4SJ9-20230216125445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803899
Report Date: 02/16/2023
Date Signed: 02/16/2023 12:55:00 PM

Document Has Been Signed on 02/16/2023 12:55 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:	BEL MARIN GARDENS		FACILITY NUMBER:	216803899
ADMINISTRATOR:	LOCKERBIE, LAARNI UY		FACILITY TYPE:	740
ADDRESS:	119 MONTEGO KEY		TELEPHONE:	(628) 259-2954
CITY:	NOVATO	STATE: CA	ZIP CODE:	94949
CAPACITY:	6	CENSUS: 6	DATE:	02/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Staff, Gelaver Gonzalodo, and Administrator, Laarni Lockerbie		TIME COMPLETED:	01:05 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	At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit, and met with Staff Member, Ver Gonzalodo. Administrator, Laarni Lockerbie, arrived later during visit at approximately 10:00AM. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival at the facility, LPA had their temperature checked and logged. LPA answered a standard COVID-symptom questionnaire. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a cleaning and disinfecting schedule that occurs twice per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for Residents. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders. LPA and Administrator discussed the following: Covid and Influenza A Protocols Staffing Resources and Staff Training Incident/Death Reports and Reporting Requirements Annual Inspection Expectations Facility has a plan in place if a staffing shortage were to occur. Facility has submitted their Mitigation/Infection Control Plan to Community Care Licensing (CCL). Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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 3

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: BEL MARIN GARDENS	FACILITY NUMBER: 216803899
	VISIT DATE: 02/16/2023

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
26
27
28
29
30
31
32

Continued from LIC809

Fire extinguishers were last serviced August 2022. The last facility fire and evacuation drill was conducted in December 2022. Smoke Detectors and Carbon Monoxide alarms were tested and operational.

LPA requested the following documents to update facility file:

Facility Documents

Administrative Organization (LIC 309)
Affidavit regarding Client/Resident Cash Resources (LIC 400)
Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Current Administrator Certificate
Surety Bond (LIC 402)
Liability Insurance
Updated Register of Clients/Residents (LIC 9020)

Facility Documents to be submitted to CCL by due date of Monday, March 16th, 2023.

*Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 02/16/2023 12:55 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: BEL MARIN GARDENS	FACILITY NUMBER: 216803899
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(2)

87211 Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Record review and Interviews conducted, the Licensee did not comply with the section cited above, and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.
	POC Due Date: 02/27/2023
	Plan of Correction
1 2 3 4	Licensee to provide training to all Staff and review the Regulation: 87211 Reporting Requirements, how to properly fill out the LIC 624 form, and provide information on where to submit them. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 2/27/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3