Bello Gardens Assisted Living

Type of visit: Required - 1 Year

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... 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 Rosterthe state’s words, verbatim · CDSS document, Oct 14, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff hit resident in care

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation. LPA met with Administrator, Frank Nola. Complaint alleges a staff hit a resident in care. On 12/31/2024 the department received an (SOC 341) unusual incident report indicating on the morning of 12/28/2024 a resident (R1) had been struck from behind by a staff (S1), resulting in difficulty standing or walking. On 1/2/2025 Community Care Licensing (CCL) received a self-reported incident report from the facility indicating they were informed of an alleged incident on said date at approximately 7:45am after breakfast in the dining room, where other residents and staff were. R1 was returning to their room upstairs, while passing S1, R1 made a derogatory statement to S1 at which time it is alleged S1 started beating with fists on R1. There were no witnesses and alleged incident was not reported until the following day to staff, at which point S2 investigate/assessed R1 finding no injuries noted. Continue on LIC9099-C Unsubstantiated Continued from LIC9099 Marin Central Police Authority report of 12/30/2024, Suspended. Interviews conducted by officers at the scene found that resident (R1) did not show any discoloration indicating any bruising on area. LPA Interviews with 3 staff, informed they have never observed S1 act aggressive and or towards any resident. Interview with R1 indicated they were beaten on with fists although when they went to the physician’s the following day there was no bruising. Physician’s report of 12/31/2024 does not indicate R1 was assaulted. Based on the Departments investigation, Interviews conducted and documents obtained, allegation staff hit a resident in care is Unsubstantiated. Although the allegation may be true, based upon the review of documents and statements provided, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the complaint is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Mar 13, 2025 · control 21-AS-20241231090356

Type of visit: Required - 1 Year

At approximately 9:45 AM, Licensing Program Analysts (LPAs) Julie Florio and Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and were greeted by Staff. Designated Responsible Party (DRP), Frank Nola, was contacted and arrived at approximately 10:20 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with 19 residents in care. Facility has a Dementia Care Plan, is approved for 11 non-ambulatory residents, bedridden residents on first floor only, and has a Hospice waiver for 5. Facility currently has one (1) Hospice resident in care. At approximately 10:40 AM, LPAs initiated a tour of the facility with DRP and observed the following: Facility is a two story converted convent, was a comfortable temperature, and passageways were free from obstructions. LPAs observed an evacuation chair at each stairwell for emergency prepairdness. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs 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. LPAs observed a 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. However, LPAs observed at least three instances of expired food and several instances of unlabeled opened or unsealed food items throughout facility freezers and refrigerators, (see LIC809D). Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPAs observed two (2) locked sheds in the backyard which LPAs inspected and observed the contents to consist of PPE supplies, extra resident care equipment, holiday decorations, chemicals and tools. Continued on LIC809-C... Continued from LIC809C... LPAs observed an activity schedule and residents attending a live music session in the facility's activity room during inspection. LPAs observed games, activities, crafts, movies, musical instruments and more for residents in care. Facility has internet access and provides an internet access device for resident use. Facility has a telephone which was tested during inspection. Facility's fire extinguishers were observed charged and were last serviced 06/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Centralized Fire system is inspected annually. Facility conducts bi-yearly disaster drills. However, Facility was unable to provide proof of completion on for any drills this year, (see LIC809D). Additionally, LPAs advised DRP that drills shall be conducted on a quarterly basis to bring the facility into compliance with regulation. LPAs observed the facility's infection control plan, first aid kit, PPE, and emergency supplies. LPAs reviewed facility's emergency disaster plan last updated 10/2024. At approximately 12:15 PM, LPAs conducted file review. Six (6) staff files and six (6) resident files were reviewed. All staff files reviewed have all of the required paperwork except Staff 1 (S1) was missing proof of negative TB results; S1, Staff 2 (S2), and Staff 3 (S3) were missing proof of at least 20 hours of required initial training; and S1, S2, S3, and Staff 4 (S4) were missing proof of the required 16 hours of medication training shadowing, (see LIC809Ds). All staff had proof of CPR and First Aid training. Six (6) of six (6) resident files reviewed contained the required documentation per regulation. However, Resident 1 (R1) was missing proof of negative TB results and a signed admissions agreement; Resident 2 (R2) was missing a consent for emergency medical treatment and a signed care plan; and Resident 3 (R3) and Resident 4 (R4) were both missing signed care plans as well, (see LIC809Ds). DRP 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. However, LPAs observed at least one (1) medication not recorded into the resident's centrally stored medication record and other instances of medications being improperly recorded, (see LIC809D). continued on LIC809C... continued from LIC809C... Required Change of Administrator Documents: LIC 308 (Designation of Facility Responsibility) Active and Current Administrator Certificate First Aid Certificate LIC 500 (Personnel Report) LIC 501 (Personnel Record) LIC 503 (Health Screening Report - personnel) Proof of Negative TB test LIC 9182 (Criminal Record Exemption Transfer Request) LIC 508 (Criminal Record Statement) Copy of Driver's License or Passport that is not expired Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations) Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: Proof of Liability Insurance (updated) Proof of property ownership Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted with DRP and Appeal rights were given. Signature on form confirms receipt.the state’s words, verbatim · CDSS document, Dec 30, 2024

The state marks this report as 10 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

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 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 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 Insurancethe state’s words, verbatim · CDSS document, Oct 19, 2023

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.