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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803239
Report Date: 10/14/2025
Date Signed: 10/14/2025 04:39:02 PM

Document Has Been Signed on 10/14/2025 04:39 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/
DIRECTOR:		NOLA,FRANKFACILITY TYPE:
740
ADDRESS:46 MARIPOSA AVENUETELEPHONE:
(415) 453-3494
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 25CENSUS: 23DATE:
10/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Frank Nola, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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At approximately 10:10 AM, Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a required 1-year annual inspection and was greeted by Staff. Administrator, Frank Nola, was contacted and arrived at approximately 11:00 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with 23 residents in care. Facility has a Dementia Care Plan, is approved by San Anselmo Fire District for 14 ambulatory & 11 non-ambulatory residents, bedridden residents on first floor only, and has a Hospice waiver for 5. Facility currently has three (3) Hospice resident in care.

At approximately 10:20 AM, LPA initiated a tour of the facility with Staff Walter and observed the following: Facility is a two story converted convent, was a comfortable temperature, and passageways were free from obstructions. LPA observed an evacuation chair at each stairwell for emergency prepairdness. Water temperatures in 6 of 6 residents' bathrooms/communal bathrooms measured, within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed menu posted throughout the facility, and facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency Food and water supply. Medications were centrally stored and locked in two med carts. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed two (2) locked sheds in backyard which LPA inspected and observed the contents to consist of PPE supplies, extra resident care equipment, holiday decorations, chemicals and tools.

Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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 10/14/2025 04:39 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/14/2025 at 02:42 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
, 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: 10/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA's & Administrator interview and record review, the licensee did not comply with the section cited above in 3 out of 6 residents (R2, R3, & R4) R2 & R4's reappraisals were from 2023 & R 3 did not have a Reappraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2025
Plan of Correction
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Licensee/Administrator agrees to arrange a meeting with parties outlined in regulation 87463(a) and update appraisals for noted residents. Licensee will submit self certification that all appraisals have been updated per regulation 87463 by POC due date, 10/24/2025 to clear the citation.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Administrator's interview & record review, the licensee did not comply with the section cited above in 1 out of 6 resident files reviewed did not have a signed Admissions Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2025
Plan of Correction
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Administrator to submit signed Admission Agreement & Signed Personal Rights page to LPA/CCL by POC due date 10/24/2025 to clear citation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELLO GARDENS ASSISTED LIVING
FACILITY NUMBER: 216803239
VISIT DATE: 10/14/2025
NARRATIVE
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Continued from LIC809C...
Facility's fire extinguishers were observed charged and were last serviced 6/2024 (see LIC9102TA). Smoke and Carbon Monoxide detectors were tested and operational during inspection. Centralized Fire system is inspected annually. Facility conducts quarterly disaster drills in different shifts with the last being 8/28/2025.

At approximately 12:15 PM, LPA conducted file review. Six (6) resident files and six (6) staff files were reviewed. Six (6) of six (6) resident files reviewed contained the required documentation per regulation. However, Resident 1 (R1) was missing signed admissions agreement & Signed Personal Rights (see LIC809D); Residents (R2, R3, & R4) were either missing or had reassessments/care plans that were from 2023, (see LIC809D).

All staff files reviewed have all of the required paperwork except Staff 1 (S1) was missing proof of negative TB results and Health screening was unled gable (see LIC9102 TA). All staff had proof of CPR and First Aid training as well as Annual required trainings.

Administrator states residents' families coordinate residents' medical and dental appointments and transportation to and from visits. Medications were reviewed and observed managed and maintained within regulation. Administrator Certificate for Frank Nola #6072967740 exp. 1/5/2027.

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 Administrator to update and submit the following documents to CCL by 11/7/2025:


LIC 308 Designation of Responsibility (if changes)
LIC 309 Administrative Organization
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (only if changes) LIC9020 Resident Roster
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
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