<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803899
Report Date: 03/06/2024
Date Signed: 03/06/2024 11:49:01 AM


Document Has Been Signed on 03/06/2024 11:49 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BEL MARIN GARDENSFACILITY NUMBER:
216803899
ADMINISTRATOR:LOCKERBIE, LAARNI UYFACILITY TYPE:
740
ADDRESS:119 MONTEGO KEYTELEPHONE:
(628) 259-2954
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:6CENSUS: 6DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Laarni LockerbieTIME COMPLETED:
12:00 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
Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:00AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit, Administrator, Laarni Lockerbie arrived shortly after.

LPA initiated a tour of the facility around 9:25AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 115 and 116 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked.

Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the garage along with Personal Protective Equipment. Fire extinguishers were last serviced September 7, 2023. Smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 02/01/2024.

Five staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Staff have required training. LPA and Administrator discussed updating residents needs and services plans annually or whenever there is a change in condition. Administrator Certificate for Administrator, Laarni Lockerbie (6025647740) is up to date and expires 04/11/2025. Medications and medication records were reviewed.


Continued on LIC809C
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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


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: 03/06/2024
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

No deficiencies cited during inspection.

Administrator to submit updates of the following documents by 04/06/2024:
LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 9020 Register of Residents

Emergency Disaster Plan (If any changes)
Infection Control Plan (If any changes)

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2