Bellaken Garden

Type of visit: Required - 1 Year

On 02/09/2026 at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Executive Director, Jeffrey Tong, and explained the purpose of the visit. The facility is currently at max capacity with 58 residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 68.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 107.3 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/20/2025. At 11:15AM, LPA reviewed five (5) resident files and five (5) staff files, all found to be complete. The emergency disaster plan was last reviewed 11/03/2025. Quarterly emergency drills were last conducted 01/22/2026. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Feb 9, 2026

Allegation investigated: Lack of Supervision

On 12/09/25 at 2:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Jeffery Tong, Administrator and explained the purpose of the visit. R1 was admitted to the facility on 5/11/23 with a diagnosis of dementia. All the facility staff reported that R1 is a quiet resident and keeps to herself mostly in her room. R1 does attend Center for Elders Independence once a week. Facility staff also report that R1 has never expressed to them any concerns about other residents bothering her. ***continues on LIC9099C** Unsubstantiated ***report from LIC9099*** R1 lives on the third floor of the facility. Review of the facility’s staff schedule revealed that there are 3 staff on duty from 6 AM till 11 PM and 2 staff on duty from 11 PM to 6 AM on the third floor. S1 and S4 both stated that they feel this is an adequate number of staff and they have not had any issues on the overnight shift. LPA interviewed R1 in her room at the facility. R1 was pleasant and neatly dressed. R1 reported that she likes living at the facility and that the staff help clean her when she needs help. LPA asked if any male resident or staff have ever touched her and R1 replied “no”. This agency has investigated the complaint alleging lack of supervision. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 15-AS-20251006151105

Type of visit: Required - 1 Year

On 2/20/25, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Jeffrey Tong, Administrator and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 106.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 8/5/24. Emergency Disaster Plan was last posted on 11/4/24. First aid kit was observed to be complete. Fire drill was last conducted on 1/22/25. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Resident sustained an ulcer in care at the facility due to staff neglect.

On 2/21/24 at 10:30 a.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver findings for the above allegation. LPA met with Jeffrey Tong, Administrator and explained the purpose of the visit . During the course of investigation, the Department interviewed: W1, W2, 5 facility staff (S1, S2, S3, S4 and S5) and 3 facility residents (R1, R2 and R3). The Department also reviewed R1’s medical records. On 9/22/2022 R1 was admitted to Bellaken Garden and had a stage one pressure injury on her back. Facility staff informed the family and made a note in R1’s admission documents that R1 had a stage one pressure injury to her back. R1 was admitted to Kaiser Hospital on 11/15/22. A review of the medical records from Kaiser Permanente (11/15/22 – 11/19/22) showed a total of three pressure injuries that never progressed past stage two. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Review of home health records (11/19/22) showed that when R1 was released from Kaiser Permanente on 11/19/2022 before returning to the assisted living side of Bellaken Garden, the home health nurse noted that R1 needed skilled nursing care. While in the assisted living side of Bellaken Garden R1's pressure injuries progressed from stage 3 to unstageable. R1 stayed in assisted living of Bellaken Garden for two weeks before she was transferred to the skilled nursing side of Bellaken Garden due to waiting on doctor approval. R1 continued to receive home health nurse services until her transfer to skilled nursing. The Department has investigated the complaint alleging a resident sustained an ulcer in care at the facility due to staff neglect. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 15-AS-20230206152229

Type of visit: Required - 1 Year

On 2/21/24 at 11:00 AM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Jeffrey Tong, Administrator and explained the purpose of the visit. The facility’s fire clearance was approved for 58. LPA toured the facility including but not limited to residents’ bedrooms, bathrooms, activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. The hot water temperature in a shared residents' bathroom was measured at 106.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 8/15/23. Emergency Disaster Plan was last posted on 11/06/23. First aid kit was observed to be complete. LPA reviewed 5 residents records and 5 staff records and all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 21, 2024