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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803899
Report Date: 02/13/2025
Date Signed: 02/13/2025 03:38:37 PM

Document Has Been Signed on 02/13/2025 03:38 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BEL MARIN GARDENSFACILITY NUMBER:
216803899
ADMINISTRATOR/
DIRECTOR:		LOCKERBIE, LAARNI UYFACILITY TYPE:
740
ADDRESS:119 MONTEGO KEYTELEPHONE:
(628) 259-2954
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Normita Uy, Staff Member
Armela Monte, Staff Member		TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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02/13/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently six (6) residents in care. Facility approved/cleared for (6) non-ambulatory only. Hospice waiver for three (3). Administrator was unable to attend as they were out of the country during the inspection. Facilities designated staff member, Normita Uy assisted LPA during inspection.

At approximately 12:35pm, LPA and Staff Member toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled. Facility has extra food storage located in the garage along with Personal Protective Equipment.

All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available located in the bathrooms storage cabinets. Water temperature in sinks accessible to residents in care were measured at 114.0 and 110.3 which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 09/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility conducts quarterly fire and disaster drills with the last one being conducted 11/20/2024. Sharps were located in a kitchen cabinet being locked and secured. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of 3 resident records. All records had the required documentation. LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

Continued to LIC809-C

Kimberley MotaTELEPHONE: (707) 588-5071
Anthony LoeraTELEPHONE: (707) 588-5026
DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BEL MARIN GARDENS
FACILITY NUMBER: 216803899
VISIT DATE: 02/13/2025
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No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/13/2025:

LIC500- Personnel Report
LIC309- Administrative Organization
Liability Insurance
Infection Control Plan (review, update if any changes)
Emergency Disaster Plan (review, update if any changes)

Exit interview conducted with Staff Member and a copy of this report was provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
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