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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 05/04/2022
Date Signed: 05/04/2022 02:12:26 PM

Document Has Been Signed on 05/04/2022 02:12 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BELLO GARDENS ASSISTED LIVINGFACILITY NUMBER:
216803239
ADMINISTRATOR:VIERRA, CHARLEENFACILITY TYPE:
740
ADDRESS:46 MARIPOSA AVENUETELEPHONE:
(415) 453-3494
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 25CENSUS: 22DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Charleen VierraTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator Charleen Vierra who arrived approximately 45 minutes later.

When LPA knocked on facility front door multiple times and no one answered, LPA walked in without any wonder guard alarms (auditory device') going off. LPA waited 7 minutes inside front entrance for staff to respond. When Administrator arrived LPA discussed requirements and regulations of safety code.

The purpose of this case management inspection is to follow up on a self reported incident, SOC 341 to Community Care Licensing (CCL) received on 5/3/2022 regarding resident (R1) who has claimed was raped by a staff (S1) on 4/29/2022 and told a friend via text.

Resident has Young Onset Alzheimer's Disease and recently changed doctors who then due to an obsessed appetite new doctor prescribed new medication. R1 had appreciated S1 for providing food but after the old medication wore off R1 became confused and suspicious.

Facility did report incident to the local Police and Local Long Term Care Ombudsman who came out and interviewed resident and staff. CCL has requested copy of investigation. LPA conducted interviews and obtained records at todays visit.


Appeal Rights Given.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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Document Has Been Signed on 05/04/2022 02:12 PM - It Cannot Be Edited


Created By: Shannan Hansen On 05/04/2022 at 01:45 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BELLO GARDENS ASSISTED LIVING
FACILITY NUMBER: 216803239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2022
Section Cited
CCR
87705(j)

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Care of Persons with Dementia The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement was not met by:
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Administrator to ensure that all exits are alarmed and operational at all times; ensuring the safety and well being of residents in care at all times.Administrator to submit plan of correction showing knowledge and understaning of regulation 87705 and facility procedures regarding 87705. Submit POC to Licensing by 5/5/22.
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LPA observed that the exit door to the front of the facility had the auditory high and low alarms were turned off.This is an immediate Health and Safety Risk to residents 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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022


LIC809 (FAS) - (06/04)
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