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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440703228
Report Date: 10/08/2025
Date Signed: 10/08/2025 01:55:15 PM

Document Has Been Signed on 10/08/2025 01:55 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HANOVER GUEST HOMEFACILITY NUMBER:
440703228
ADMINISTRATOR/
DIRECTOR:		MARSHA BELLEZAFACILITY TYPE:
740
ADDRESS:813 HANOVER STREETTELEPHONE:
(831) 426-0618
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 15CENSUS: 9DATE:
10/08/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator Marsha BellezaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Other visit regarding the death of Licensee Ramon Bellezan and to follow up on non-payment of civil penalties. LPA met with Administrator (ADM) Marsha Belleza. LPA stated the purpose of the visit.

During visit, LPA and ADM met with LPM Romeo Manzano on a teams meeting. ADM acknowledged receiving the civil penalty letters in the mail. ADM states she was not ignoring the civil penalties, but was unable to pay due to her 'budget' and not having enough residents. ADM stated she will submit a letter requesting a payment plan for the civil penalties to the Department. ADM stated Licensee Ramon Belleza passed away in 2015. Based on facility file review, the facility is a partnership between Licensee Ramon Belleza and ADM's husband. Based on stipulations of the partnership, upon the death of any partner, the partnership is dissolved. The Department was not notified of the Licensee’s death until 10/7/2025. ADM stated she was not aware she was required to report the death to the Department. According to ADM, her husband is not involved with the facility, and has his own business. ADM states her husband was currently out of the state and unable to join the meeting. LPA and LPM informed ADM the facility must be licensed in order to continue to operate.

After the meeting, ADM stated she will obtain licensure through the Department. LPA provided ADM with the website for ASCP Centralized Application Bureau. LPA also provided ADM with hard copies of the following documentation to submit for Change of Administrator for Staff Wendy Sanchez:

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NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228
VISIT DATE: 10/08/2025
NARRATIVE
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•LIC501
• LIC500
• LIC200
• LIC308
• LIC 9182

ADM also stated she will provide the Department with copies of the control of property, deed to the property and additional documentation regarding the property.

ADM was advised to inform residents about the Change of Ownership (CHOW) as she plans to seek licensure for the facility.

Deficiencies are being cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with ADM Marsha Belleza, and ADM requested LPA to not read the report. ADM stated she would read the report privately. ADM signed the report and LPA provided ADM with a copy and appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2025 01:55 PM - It Cannot Be Edited


Created By: Marcella Tarin On 10/08/2025 at 01:19 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HANOVER GUEST HOME
FACILITY NUMBER: 440703228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2025
Section Cited
CCR
87111(b)(1)

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87111 Continuation of License Under Emergency Conditions (b) In the event of a licensee's death...(1) notify the Department by the next working day of the licensee’s death
This was not met as evidenced by:
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ADM will submit a statement of understanding of the regulation cited and submit to CCLD by POC due date of 10/9/2025.
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Based on interview and record review, the ADM did not inform the Department of the death of the Licensee by the next working day. ADM stated the Licensee died in 2015, which poses an immediate health, safety and personal rights risk to persons in care.
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Type A
10/09/2025
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties(a) The administrator shall.. permit adequate attention to the management and administration of the facility as specified in this section.

This was not met as evidenced by:
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ADM will submit a letter of understanding of Administrator Qualifications and Duties and submit an updated LIC500 to include the days and times she is at the facility. ADM will submit POC to CCLD by POC due date of 10/9/2025.
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ADM acknowleges non-payment of civil penalties. ADM states she is unable to pay due to her 'budget' and not having enough residents, which poses an immediate health, safety, and personal rights risks to persons 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.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2025


LIC809 (FAS) - (06/04)
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