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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:10:38 PM

Document Has Been Signed on 10/19/2023 04:10 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:NEYSA HINTONFACILITY TYPE:
740
ADDRESS:46 MARIPOSA AVENUETELEPHONE:
(415) 453-3494
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 25CENSUS: 22DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Neysa HInton, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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License Program Analyst (LPA’s) Hansen and Rummonds arrived unannounced to conduct an Annual Required – 1 yr. visit of the facility. LPA’s had caregiver Josefa Mancinas contact Administrator who arrived during the inspection. There is a total of 22 residents. There is 2 residents currently on Hospice and some residents with Dementia.

LPA’s entered the facility with auditory alarm going off and waited in entrance room for approximately 7 minutes observing other residents walking the halls and then went to find care staff, all of which were in dining area (see LIC809-D) LPA’s toured the facility on 10/19/2023 at 9:15 AM with Josefa Mancinas; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 6/29/2023 at the time of the visit. Facility smoke detectors were tested and found to be operational at the time of the visit. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 10/5/2023. LPAs observed Carbon monoxide detectors that were found to be operational during the visit. There is a backup generator that powers many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 110.4 degrees F and 100.4 degrees F. falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 6 of 9 resident’s bathrooms while touring facility on 10/19/2023 at 10:25AM (see LIC809-D).

Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPAs toured the kitchen area on 10/19/2023 at 10:00 AM; although toxins were observed stored with food in kitchen (see LIC809-D). Food is available for residents any time of the day. There is a daily activity schedule for residents.

Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 10/19/2023 04:10 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/19/2023 at 01:57 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: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations, the Licensee did not comply with the section cited above. LPAs observed cleaning supplies , vitamins, razors, and toxins in residents' bathroom and paint on back patio that were unlocked and accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(2). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 10/20/2023, and Training to be submitted by due date of 10/23/2023.
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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2023 04:10 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/19/2023 at 01:57 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: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview with S1 the licensee did not comply with the section cited above as facility had Lysol, comet, & rust remover stored with food supply (see pictures) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Licensee agrees to ensure food items are stored separately from soaps, detergents and cleaning compounds. Licensee to submit written plan detailing how facility will keep food items stored away from other items and photo evidence the current food items are separated from soaps and cleaning compounds. Written plan to be submitted to CCL by POC date of 10/23/2023.
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) 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 is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the licensee did not comply with the section cited above, when LPA's entered facility, auditory alarm went off altough staff did not respond for the 5 minutes LPA's stood inside front door, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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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 10/23/23
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: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


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Document Has Been Signed on 10/19/2023 04:10 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/19/2023 at 02:23 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: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (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 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the water temperature tested in 6 out of 9 bathrooms accessible to residents was between 100.4 degrees F & 104.3 degrees F, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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 Administragtor to submit a log of water temperature from 10/20/23 to 10/27/2023. Licensee to submit a written statement that they understand the regulation and will be in future compliance by POC due date 07/14/2023
Type B
Section Cited
CCR
87625(b)(3)
87625 Managed Incontinence - (b)...the licensee shall be responsible for the following: (3) Ensuring ...that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, Administrator did not ensure the regulation above due to Resident bedroom & downstairs facility bathroom having a strong foul odor of urine. This is a potential personal rights and health risk to residents in care.
POC Due Date: 10/23/2023
Plan of Correction
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Administrator to train all staff submit copies of staff training on regulation 87626(b)(3). Training to include the date, time, duration, subject, instructor, staff's name and signature. Training to be submitted to Community Care Licensing (CCL) by POC due date 10/23/2023
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: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 10/19/2023 04:10 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/19/2023 at 02:46 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: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(3)(c)


(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. (c) The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview with staff, the licensee did not comply with the section cited above when finding 3 hand and body towels in joint bathrooms and interview with staff who stated "towel is there in bathroom for all the people to use" which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Licensee/Administrator to ensure all facility shared resident batthrooms have papertowels available for resident use as needed as common hand towels/any common towels are prohibited.Submit plan of correction and ensure compliance with the regulation in regards to paper towels in resident bathrooms for use as needed. .POC due 10/23/23.
Type B
Section Cited
CCR
80087(a)

80087(a)Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's & Administrator's observation during tour of facility , the licensee did not comply with the section cited above finding side door window shattered & taped together which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee must maintain the facility clean, safe, sanitary, and in good repair at all times. Facility agrees to ensure that the entire facility will be clean and in good repair at all times. Facility to fix and/or replace broken stained glass window of door. Licensee to submit an LIC 9098 self-certification that facility is in good repair with picture to CCL by POC date of 10/31/2023 in order to clear the deficiency.
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: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELLO GARDENS ASSISTED LIVING
FACILITY NUMBER: 216803239
VISIT DATE: 10/19/2023
NARRATIVE
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Toxins are stored in a locked housekeeping closet and under the kitchen cabinet; although LPA’s observed toxins in resident bathroom as well as razors. While touring outside LPA’s observed multiple cans of paint on back patio accessible to residents in care (see LIC809-D) There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. LPAs observed a strong smell of urine in downstairs common bathroom & in resident (R1) bedroom on 10/19/2023 at 10:15AM (see LIC809-D). LPA’s also observed multiple bathrooms containing communal hand towels and bathrooms without paper towels (see LIC809-D). LPA’s and Administrator observed side door to facility with shattered/taped window (see LI809-D).

A sample review of five resident & five staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 11:27AM on 10/19/2023 and learned that 5 of 5 residents have update reappraisal/needs & care plan on file at this time as required by Title 22 Regulation.

Medications were centrally stored in a locked medication cabinet in the facility medication room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 10/19/2023 at 2:00PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

LPAs conducted a sample reviewed of staff records at 12:37PM on 10/19/2023 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1st Aid certification for all staff. Neysa Hinton, Administrator Certificate # 6053696740 expires on 10/30/2024.

LPAs reviewed Licensing Information System (LIS) with Administrator who stated that is current and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted quarterly with the last one being conducted on 9/29/2023.
Continue to LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 216803239
VISIT DATE: 10/19/2023
NARRATIVE
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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.

LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 11/9/2023:

Copy of Annual Sprinkler Inspection
LIC 308 Designation of Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator’s Certificate
Proof of Liability Insurance
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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