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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201373
Report Date: 12/24/2025
Date Signed: 12/24/2025 03:52:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20251219152836
FACILITY NAME:BELLARA SENIOR LIVINGFACILITY NUMBER:
019201373
ADMINISTRATOR:COLLETTE VALENTINEFACILITY TYPE:
740
ADDRESS:22400 2ND STREETTELEPHONE:
(760) 547-2863
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:175CENSUS: 123DATE:
12/24/2025
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jeff Sumabat/Executive Director TIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff did not ensure resident's informaiton is kept confidential.
INVESTIGATION FINDINGS:
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On this day, 12/24/25, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for visit.

It was alleged that the Ombudsman Program received two folders in the mail from the facility containing documentation related to resident (R1). The Reporting Party (RP) also indicated that at the time the materials were received, the Ombudsman Program had not had any contact with R1 and was therefore unable to verify whether R1 had provided consent for the release of the information.

During the course of investigation, LPA obtained copies of staff schedule and conducted interviews.

....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20251219152836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BELLARA SENIOR LIVING
FACILITY NUMBER: 019201373
VISIT DATE: 12/24/2025
NARRATIVE
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LPA interviewed the Ombudsman (W1) who confirmed they received an SOC341 along with copy of a 30-day notice, R1's financial ledger, and a bill associated with the R1's account. W1 also stated they have not obtain permission from R1 to release the documents to them. LPA interviewed the staff (ED, S2 and S3) and confirmed those documents were mailed out to Ombudsman.

Based on information obtained, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with ED.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20251219152836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELLARA SENIOR LIVING
FACILITY NUMBER: 019201373
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2026
Section Cited
HSC
1569.269(a)(3)
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ยง1569.269 Enumerated rights; severability
(a) Residents of residential care facilities for the elderly shall have all of the following rights:
(3) To confidential treatment of their records and personal information and to approve their release, except as authorized by law.
-This requirement is not met as evidenced by:
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Executive Director stated and agreed to in-service the staff. Proof to be submitted by 1/07/26.
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-Based on interviews, the licensee did not comply with the section above in providing R1's documents containing confidential information to Ombudsman Program when consent for release from R1 has not been obtained which posed a potential personal rights risk to person 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20251219152836

FACILITY NAME:BELLARA SENIOR LIVINGFACILITY NUMBER:
019201373
ADMINISTRATOR:COLLETTE VALENTINEFACILITY TYPE:
740
ADDRESS:22400 2ND STREETTELEPHONE:
(760) 547-2863
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:175CENSUS: 123DATE:
12/24/2025
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jeff Sumabat/Executive Director TIME COMPLETED:
03:55 PM
ALLEGATION(S):
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No designated staff responsible for the operation of the facility present in the absence of administrator.
INVESTIGATION FINDINGS:
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On this day, 12/24/25, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for visit.

It was alleged that on 12/19/25, ED was not at the facility and there's no designated person available.

During the course of investigation, LPA obtained copy of LIC500 Personnel Report and interviewed Ombudsman (W1) and staff (S1, S2, S3 and ED).

...continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20251219152836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BELLARA SENIOR LIVING
FACILITY NUMBER: 019201373
VISIT DATE: 12/24/2025
NARRATIVE
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W1 stated that another Ombudsman came to the facility on 12/19/25 and ED was out. W1 stated there was no designated staff in ED's absence.

S1 confirmed that he was the MOD on the said date and that Ombudsman (W2) came over and asked for R1's financial documents, however, only S4, ED and corporate have access to residents' financial records. S1 further stated he sent email that same day to W2 regarding the conversation that transpired between him and W2 and included ED and S4 on the email, however, the email didn't go through. Copy of the email confirmed S1's statement. S1 also stated that any information pertaining to residents' care, there's always staff present to provide information.

LPA interviewed ED who confirmed he was not at the facility on the said date, however, the manager on duty (MOD) that day was S1 and MOD's support was S3. ED further stated that on his days off, there's always MOD assigned. ED stated that only him, S4 and corporate have access to the residents' financial records.

S3 confirmed she was at the facility on 12/19/25. S3 and S2 both stated there's always MOD scheduled when ED is out.

Based on information gathered and review of LIC500, the allegation in unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5