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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440703228
Report Date: 09/03/2025
Date Signed: 09/03/2025 04:02:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/03/2025 04:02 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
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: 9DATE:
09/03/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator Marsha BellezaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management - Annual Continuation Visit and met with Administrator (ADM) Marsha Belleza. This annual inspection is a continuation of the annual visit that was conducted on 8/28/2025. LPA stated the purpose of the visit.

The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. The facility emergency drill log was reviewed. The facility is not conducting emergency drills for 2025. A deficiency is being issued, see LIC809-D for more information.

LPA toured 4 resident bathrooms and measured water temperatures. 3 out of 4 bathrooms water temperatures were not within range, temperatures ranged from 103.8 F to 122.5 F. A Technical Violation is being issued, see LIC9102 for more information.

During review of 3 resident records (R1 to R3), LPA observed 1 out of 3 records did not contain a medical assessment. R1's record did not contain a medical assessment. ADM states she is aware R1 does not have a medical assessment on file. A deficiency is being issued, see LIC809-D for more information.

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NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2025
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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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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Document Has Been Signed on 09/03/2025 04:02 PM - It Cannot Be Edited


Created By: Marcella Tarin On 09/03/2025 at 10:45 AM
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: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2025
Section Cited
HSC
1569.695(c)

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(c) A facility shall conduct a drill at least quarterly for each shift.... 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:
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ADM states the facility will conduct a fire drill by 9/5/2025 and submit documentation of fire drill to include the type of drill, and names of staff participation. ADM will submit POC to CCLD by POC due date 9/4/2025.
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Based on record review and interview, ADM did not ensure that the facility is conducting emergency drills for 2025, which poses an immediate health, safety and personal rights to persons in care.
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ADM states she will provide a statement of understanding of the regulation cited, and provide a timelime of when she will obtain her Administrator Certficate. ADM states she will submit the POC to CCLD by POC due date of 9/5/2025.

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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.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2025 04:02 PM - It Cannot Be Edited


Created By: Marcella Tarin On 09/03/2025 at 01:42 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: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2025
Section Cited
CCR
87355(c)

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87355 Criminal Record Clearance(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another.
This requirement is not met as evidenced by:
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ADM stated she will associate S8 and S9 to the facility. ADM stated she will send a written plan of action on how she will ensure staff are associated to the facility. ADM stated she will send this written plan of action to CCLD by POC due date 9/4/2025.
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Based on interview, observation and record review, the ADM did not ensure S8 and S9 were associated prior to working in the facility which poses an immediate health, safety and personal rights risk to persons in care.
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Type A
09/04/2025
Section Cited
CCR87411(c)(1)

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87411 Personnel Requirements(c)(1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...Staff providing care shall receive appropriate training in first aid.
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ADM stated she will schedule annual training and first aid training for 9 out of 9 staff. ADM states she will submit proof of scheduled first aid training to include name of agency providing training, and a schedule of upcoming staff trainings to CCLD by POC due date 9/4/2025
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Based on interview, observation and record review, ADM did not ensure 9 out of 9 staff received initial or annual training, and first aid training, which poses an immediate health, safety and personal rights risk to persons 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.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2025 04:02 PM - It Cannot Be Edited


Created By: Marcella Tarin On 09/03/2025 at 02:19 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: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2025
Section Cited
CCR
87458(a)

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87458 Medical Assessment (a) Prior to a person's acceptance as a resident... a medical assessment, signed by a licensed medical professional... made within the last year, to be kept in the resident's record.

This was not met as evidenced by
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ADM states she will contact R1's responsible parties to obtain a medical assessment. ADM will submit proof of communication with R1's responsible parties to CCLD by POC due date 9/4/2025.
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Based on record review and interview, R1's record did not contain a medical assessment, which poses an immediate health, safety and personal rights risk to persons 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.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228
VISIT DATE: 09/03/2025
NARRATIVE
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During review of 9 staff records, LPA observed all 9 staff records did not contain training and first aid training. A deficiency is being issued, see LIC809-D for more information.

LPA also observed S8 and S9's staff record was missing documentation. Upon further review of staff through the facility Guardian roster, S8 and S9 were not associated to the facility, but had obtained fingerprint background clearance. ADM states she is aware S8 and S9 have not been associated and had difficult accessing the facility Guardian account. ADM states S8 has worked at the facility since 1/7/2025 and S9 has worked at the facility since 8/24/2024.

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 S8 working in the facility without association. Another civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S9 working in the facility without association. See LIC421BG.

LPA provided ADM with a pamphlet for Community Care Licensing Division (CCLD) Technical Support Program (TSP).

An exit interview was conducted with Administrator (ADM) Marsha Belleza and signed copy of this report was provided. Appeal rights were also provided during visit.

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END OF REPORT.
NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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