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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440703228
Report Date: 08/24/2026
Date Signed: 09/02/2026 09:13:15 AM

Document Has Been Signed on 09/02/2026 09:13 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HANOVER GUEST HOMEFACILITY NUMBER:
440703228
ADMINISTRATOR/
DIRECTOR:		MARSHA BELLEZAFACILITY TYPE:
740
ADDRESS:813 HANOVER STREETTELEPHONE:
(831) 426-0618
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 15CENSUS: 11DATE:
08/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Staff S1 Alicia Correa
Administrator Marsha Belleza		TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Staff S1 Alicia Correa Olvera. LPA stated the purpose of the visit. Staff S1 stated Administrator (ADM) Marsha Belleza and Designated Staff Wendy Sanchez were not at the facility. ADM arrived to the facility at 12:27 PM.

LPA toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction.

LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the refrigerator temperature at 40 F and Freezer at 0 F.

LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care.

LPA did not observe smoke detectors in the facility during inspection. ADM stated each room had a smoke detector, but is not able to find smoke detectors for each room. ADM states smoke detectors were installed two months ago, but does not know what happened to the smoke detectors in the residents. Fire extinguishers were last serviced on 1/22/2026. ADM was advised to purchase and install smoke detectors by 8/25/2026. A deficiency is being issued.

Page 1 of 2
Christine Kabariti
Marcella Tarin
DATE: 08/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228
VISIT DATE: 08/24/2026
NARRATIVE
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LPA reviewed the facility first aid kit, the first aid kit did not contain tweezers. LPA advised ADM to purchase a pair of tweezers. LPA reviewed the facility emergency drill logs, with the last drill being conducted on 9/12/2025. ADM stated the facility will conduct a drill by 8/28/2026. A deficiency is being issued.

LPA toured 6 resident bedrooms. All 6 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 3 bathrooms. All 3 bathrooms had hand soap, hand towels, functioning lights, and covered trash bins. LPA measured water temperature with a range of 120.7 F to 138.0 F in the 3 bathrooms at approximately 12:00PM. ADM adjusted water heater during visit, however, water temperature measured 130.4 F at 3:40PM. A deficiency is being issued.

LPA reviewed 2 resident records.

LPA reviewed 2 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s).

LPA reviewed 3 staff records. 2 Out of 3 staff records did not contain current CPR/first aid training and did not contain current caregiver training for 2026. A deficiency is being issued. S3 did not have a staff record, and S3 did not obtain a fingerprint clearance. A deficiency is being cited.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S3 working in the facility without receiving a criminal record background clearance. An exit interview was conducted with Administrator Marsha Belleza and a signed copy of this report was provided.

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END OF REPORT

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/02/2026 09:13 AM - It Cannot Be Edited


Created By: Marcella Tarin On 08/24/2026 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, the licensee did not comply with the section cited above. LPA did not observe smoke in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2026
Plan of Correction
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ADM will submit a Plan of Action (POC) stating how she will ensure the facility has smoke detectors. ADM will purchase and install smoke detectors by 8/25/2026 and submit pictures to CCLD as part of the POC. The POC will be due by 8/25/2026 to CCLD.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 3 Out of 3 resident bathroom water temperatures measured between 120.7 F to 138.0 F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2026
Plan of Correction
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ADM will submit a Plan of Action (POC) stating how she will ensure faucets used by residents are within range of 105 F to 120 F. The POC will be due by 8/25/2026 to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2026 09:13 AM - It Cannot Be Edited


Created By: Marcella Tarin On 08/24/2026 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. ADM states the facility has not conducted a fire drill since 9/12/2025 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2026
Plan of Correction
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ADM will submit a Plan of Action (POC) stating how she will ensure the facility is conducting a drill at least quartely for each shift. The POC will be due by 8/25/2026 to CCLD.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2026 09:13 AM - It Cannot Be Edited


Created By: Marcella Tarin On 08/24/2026 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. 2 Out of 2 staff did not have current caregiver training for 2026, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2026
Plan of Correction
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ADM will submit a Plan of Action (POC) stating how she will ensure facility staff receiving appropriate caregiver trainings to include but not limited to dementa care, postual supports, etc. The POC will be due by 8/31/2026 to CCLD.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2026 09:13 AM - It Cannot Be Edited


Created By: Marcella Tarin On 08/24/2026 at 03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. S3 did not obtain a fingerprint background clearance prior to working in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2026
Plan of Correction
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ADM will submit a Plan of Action (POC) stating how she will ensure all staff obtain a fingerprint background clearance prior to working in the facility. The POC will be due by 8/25/2026 to CCLD.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2026 09:13 AM - It Cannot Be Edited


Created By: Marcella Tarin On 08/24/2026 at 03:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above. 2 Out of 2 staff did not have CPR and first aid training for 2026,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2026
Plan of Correction
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2
3
4
ADM will submit a Plan of Action (POC) stating how she will ensure all staff obtain CPR and first aid training. The POC will be due by 8/25/2026 to CCLD.
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.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2026


LIC809 (FAS) - (06/04)
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