Inspection Reports for
Bellaken Garden

2780 26TH AVENUE, OAKLAND, CA, 94601

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 3.4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

15% better than California average
California average: 4 deficiencies/year

Deficiencies per year

8 6 4 2 0
2022
2023
2024
2025
2026

Occupancy

Latest occupancy rate 100% occupied

Based on a February 2026 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy rate over time

40% 60% 80% 100% 120% Mar 2022 Feb 2023 Feb 2025 Feb 2026

Inspection Report

Annual Inspection
Census: 58 Capacity: 58 Deficiencies: 0 Date: Feb 9, 2026

Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to assess compliance with licensing requirements.

Findings
The facility was found to be at maximum capacity with 58 residents. The inspection found no deficiencies; all areas including resident files, staff files, medication administration, and safety equipment were in compliance.

Report Facts
Fire extinguisher last serviced date: Aug 20, 2025 Emergency disaster plan last reviewed: Nov 3, 2025 Quarterly emergency drills last conducted: Jan 22, 2026 Indoor temperature: 68 Hot water temperature: 107.3 Resident files reviewed: 5 Staff files reviewed: 5

Employees mentioned
NameTitleContext
Jeffrey TongExecutive DirectorMet with Licensing Program Analyst during inspection
Andrew ChristyLicensing Program AnalystConducted the inspection
Harpreet HumpalLicensing Program ManagerNamed in report header

Inspection Report

Complaint Investigation
Census: 58 Capacity: 58 Deficiencies: 0 Date: Dec 9, 2025

Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of lack of supervision at the facility.

Complaint Details
The complaint alleging lack of supervision was investigated and found to be unsubstantiated due to insufficient evidence to prove the violation occurred.
Findings
The investigation found no preponderance of evidence to prove the alleged lack of supervision occurred. The complaint was determined to be unsubstantiated.

Report Facts
Capacity: 58 Census: 58

Employees mentioned
NameTitleContext
Gregory ClarkLicensing Program AnalystConducted the complaint investigation
Jeffery TongAdministratorMet with the Licensing Program Analyst during the investigation

Inspection Report

Annual Inspection
Census: 52 Capacity: 58 Deficiencies: 0 Date: Feb 20, 2025

Visit Reason
The visit was an unannounced 1-Year Annual Required inspection conducted to evaluate facility compliance with licensing regulations.

Findings
The facility was toured and inspected, including resident rooms and safety equipment. No deficiencies were cited during the visit, and all reviewed resident and staff records were complete.

Report Facts
Fire extinguisher last serviced: Aug 5, 2024 Fire drill last conducted: Jan 22, 2025 Hot water temperature: 106.5

Employees mentioned
NameTitleContext
Jeffrey TongAdministratorMet with Licensing Program Analyst during inspection
Gregory ClarkLicensing Program AnalystConducted the inspection visit

Inspection Report

Deficiencies: 1 Date: Nov 7, 2024

Visit Reason
The inspection was conducted to assess compliance with staffing requirements, specifically to verify that the facility had a registered nurse on duty for at least eight hours a day, seven days a week, as required by policy.

Findings
The facility failed to ensure registered nurse coverage for eight hours a day, seven days a week, with payroll data confirming no RN coverage on June 3, 10, and 17, 2023. This failure had the potential to endanger resident health and safety.

Deficiencies (1)
Failure to have a registered nurse on duty eight hours a day, seven days a week.
Report Facts
Dates without RN coverage: 3

Employees mentioned
NameTitleContext
Director of NursingDirector of NursingInterviewed regarding importance of RN coverage and resident safety risk
AdministratorAdministratorInterviewed and confirmed no RN coverage on specified dates

Inspection Report

Complaint Investigation
Census: 51 Capacity: 58 Deficiencies: 0 Date: Feb 21, 2024

Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident sustained an ulcer due to staff neglect.

Complaint Details
The complaint alleged that a resident sustained an ulcer in care at the facility due to staff neglect. The investigation included interviews with staff and residents and review of medical records. The complaint was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the complaint was unsubstantiated. Although the resident had pressure injuries that progressed in severity, there was insufficient evidence to prove staff neglect caused the ulcer.

Report Facts
Facility Capacity: 58 Resident Census: 51

Inspection Report

Annual Inspection
Census: 51 Capacity: 58 Deficiencies: 0 Date: Feb 21, 2024

Visit Reason
The visit was an unannounced 1-Year Annual Required inspection conducted to evaluate the facility's compliance with licensing requirements.

Findings
The facility was found to be in compliance with no deficiencies cited. The environment was safe and well-maintained, with adequate lighting, temperature control, and safety equipment in place.

Inspection Report

Routine
Deficiencies: 8 Date: Dec 14, 2023

Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and vaccination protocols at Bellaken Skilled Nursing Center.

Findings
The facility was found deficient in multiple areas including failure to follow physician orders for oxygen administration, inconsistent quality control testing of blood glucose meters, improper medication disposal documentation, expired medications storage, unsafe food preparation practices, infection control lapses including improper catheter care and blood glucose meter use, failure to provide pneumococcal and COVID-19 vaccinations to some residents, and inadequate cleaning and disinfection procedures.

Deficiencies (8)
Failed to follow physician's order for oxygen administration for two residents when oxygen flow rates were not set as ordered.
Quality control tests for blood glucose meters were not done consistently and no remedial actions were taken for out-of-range results.
Unused or discontinued medications were disposed without required signatures of a pharmacist or nurse and one other witness.
An opened, used, multi-dose vial of influenza vaccine was not removed after 28 days of first use; expired medications and items were stored and not removed.
Low temperature dishwasher did not reach proper sanitation level; dietary staff did not wear hair restraints properly; staff did not wash hands upon kitchen entry; food tray dropped on floor was placed in food cart.
Urinary catheter drainage bag touched the floor; soiled towels not stored properly; laundry room daily task checklists not consistently completed; blood glucose meters not cleaned per manufacturer's instructions; single-patient use blood glucose meter used on multiple residents.
Failed to provide pneumococcal immunizations for three residents after consent was obtained.
Failed to offer and provide COVID-19 immunizations for two residents despite consent and policy.
Report Facts
Missing quality control test dates: 4 Expired medication dates: 7 Residents requiring blood glucose checks: 4

Employees mentioned
NameTitleContext
LVN 1Licensed Vocational NurseNamed in oxygen administration and blood glucose meter cleaning findings.
LVN 2Licensed Vocational NurseNamed in blood glucose meter quality control and medication cart inspection.
LVN 3Licensed Vocational NurseNamed in blood glucose meter cleaning and disinfection interview.
LVN 4Licensed Vocational NurseNamed in medication refrigerator inspection and expired vaccine finding.
DONDirector of NursingNamed in multiple interviews confirming deficiencies and policy adherence.
DSSDietary Service SupervisorNamed in food safety and sanitation findings.
IPInfection PreventionistNamed in infection control and blood glucose meter cleaning findings.
HSHousekeeping SupervisorNamed in laundry room cleanliness and checklist findings.

Inspection Report

Complaint Investigation
Census: 34 Capacity: 58 Deficiencies: 0 Date: Feb 8, 2023

Visit Reason
The inspection was conducted as a result of a priority 2 complaint to perform a Health & Safety inspection.

Complaint Details
The visit was triggered by a priority 2 complaint. No deficiencies were found, indicating the complaint was not substantiated.
Findings
The facility was toured including bedrooms, bathrooms, common areas, kitchen, and outdoor area. No deficiencies were cited during the visit; all safety and health measures were found to be in compliance.

Employees mentioned
NameTitleContext
Jeffrey TongAdministratorMet with Licensing Program Analyst during the inspection.
Gregory ClarkLicensing Program AnalystConducted the Health & Safety inspection.
Yvonne Flores-LariosSupervisorSupervisor overseeing the inspection.

Inspection Report

Routine
Census: 33 Capacity: 58 Deficiencies: 0 Date: Jan 23, 2023

Visit Reason
The visit was an unannounced Infection Control Inspection conducted as a required one-year inspection.

Findings
The facility was found to have adequate infection control measures including proper PPE use, sufficient food supply, posted visitor policies, and routine screening records. No deficiencies were cited during the visit.

Inspection Report

Routine
Census: 42 Capacity: 58 Deficiencies: 0 Date: Mar 24, 2022

Visit Reason
The visit was an unannounced Infection Control Inspection conducted as a required annual check.

Findings
The facility was toured including multiple areas such as entrance, bedrooms, kitchen, and common areas. No deficiencies were cited; the facility demonstrated proper infection control measures including PPE use, screening, and signage.

Employees mentioned
NameTitleContext
Jeffrey TongAdministratorMet during inspection and conducted facility tour.

Inspection Report

Routine
Deficiencies: 8 Date: Feb 4, 2022

Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for nursing home care and services.

Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents, lack of posting Ombudsman contact information, failure to notify residents timely about Medicare coverage ending, failure to provide podiatry services, failure to provide ordered range of motion exercises, incomplete dialysis assessments, failure to obtain informed consent for bed rail use, and inadequate infection prevention and control practices during a COVID-19 outbreak.

Deficiencies (8)
Failed to ensure call lights were within reach for three of 17 sampled residents.
Failed to post Ombudsman Program contact information.
Failed to inform Resident 32 and Responsible Party timely about Medicare services ending.
Failed to provide podiatry services for one resident for five months.
Failed to provide range of motion exercises as ordered for one resident.
Failed to perform complete assessments before dialysis treatments for one resident.
Failed to obtain informed consent from residents or family representatives prior to use of bed rails for four residents.
Failed to ensure staff followed proper infection control standards and transmission-based precautions during COVID-19 outbreak, including inadequate PPE availability and improper hand hygiene during medication administration.
Report Facts
Residents sampled: 17 Residents affected: 3 Residents affected: 1 Months: 5 Residents affected: 1 Residents affected: 1 Residents affected: 4 Isolation gowns: 4 Resident rooms: 8

Employees mentioned
NameTitleContext
Certified Nursing Assistant 3CNAMentioned in relation to call light placement for Resident 217 and Resident 17's toenail care
Certified Nursing Assistant 1CNAMentioned regarding call light cord length for Resident 50
Social Services DirectorSSDInterviewed about Ombudsman contact information
Social WorkerSWInterviewed about Medicare notification for Resident 32 and podiatry scheduling for Resident 17
Licensed Vocational Nurse 2LVNInterviewed about Resident 17's toenail care
Certified Nursing Assistant 4CNAInterviewed about toenail care documentation for Resident 17
Restorative Nurse AideRNAInterviewed about failure to provide ROM exercises to Resident 50
Director of NursingDONInterviewed about ROM exercises for Resident 50 and bed rail consent for Resident 64
AdministratorADMInterviewed about dialysis assessments and PPE supply
MDS CoordinatorMDSCInterviewed about bed rail consent and resident cognition
Licensed Vocational Nurse 1LVNObserved and interviewed about hand hygiene during medication administration
Registered Nurse 1RNObserved and interviewed about hand hygiene during medication administration
Infection PreventionistIPInterviewed about infection control practices and PPE availability
Certified Nursing Assistant 2CNAObserved and interviewed about PPE use and glove availability
HousekeeperHSKPObserved and interviewed about PPE use and glove changing

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