496804239-1-30-2025-21-AS-BMOS-DGNUGW-20250514153458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804239
Report Date: 01/30/2025
Date Signed: 01/30/2025 01:22:36 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250130095032

FACILITY NAME:	BLUEBELL MANOR		FACILITY NUMBER:	496804239
ADMINISTRATOR:	SOLOMON BANA		FACILITY TYPE:	740
ADDRESS:	1997 BLUEBELL DRIVE		TELEPHONE:	(707) 800-2522
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 5	DATE:	01/30/2025
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Caregiver-Monica Balderas		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Insufficient food supply

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Alviso and Magdaleno, conducted a complaint inspection, on 1/30/2025 at approximately 12:40pm, and met with caregiver Monica Balderas.
Reporting party alleges that the facility has an “Insufficient food supply”. LPAs observed the food supply; Food supply was found to be sufficient in perishable food and non-perishable foods. Interview with S2 identified that there is always food for resident meals, snacks, and drinks for residents in care; Staff stated that there is no concern regarding food supply to feed residents their meals. Per interviews with staff and other related parties, the food supply is sufficient and meals, drinks, and snacks are provided to all residents in care. LPAs observed numerous food items, frozen meats, vegetables, and other items for meals to be prepared. LPA has observed staff cooking meals for the residents in care during inspections recently completed.There was no information obtained during this investigation to support a violation had occurred regarding reported allegation.Based on the interviews, LPA observations, and related information obtained during the investigation, the allegation “Insufficient food supply” is Unfounded". We have found that the complaint allegations was Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiencies cited during todays visit.
Exit interviews were conducted.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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