075600885-4-26-2022-15-AS-JSAR-CDUQTC-20220426122654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600885
Report Date: 04/26/2022
Date Signed: 04/26/2022 12:28:51 PM

Document Has Been Signed on 04/26/2022 12:28 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	BELROSE CARE HOME		FACILITY NUMBER:	075600885
ADMINISTRATOR:	JUNSAY, ROSA C.		FACILITY TYPE:	740
ADDRESS:	209 NORMANDY LANE		TELEPHONE:	(925) 932-7795
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 5	DATE:	04/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Rosa Junsay		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/26/22 at 11:15AM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with administrator upon entry. Facility has a mitigation plan in place dated 01/05/2021 to mitigate the spread of COVID-19. LPA discussed the importance of having a completed mitigation plan (LIC 808) with administrator, as well as the infection control plan that she said will be complete in time for the 06/30/22 due date. LPA inspected the facility inside and outside. LPA observed the 2 live-in staff interacting with and caring for all of the 5 clients. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. A written Emergency/Disaster plan dated 01/05/20 was posted on the bulletin board for staff, clients and visitors to read. LPA spoke with administrator about the importance of updating the information in the plan with the staff living and/or working at the facility. Centrally stored medications were locked in the kitchen cabinets. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were stored in a locked closet. Infection control designated leader is the administrator. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELROSE CARE HOME	FACILITY NUMBER: 075600885
	VISIT DATE: 04/26/2022

NARRATIVE

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All staff and clients have been fully vaccinated. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the pantry and garage. However, opened food in the refrigerators and freezers were not marked with the date opened for which the facility was cited.

Facility room temperature was maintained at 72.1 degrees Fahrenheit and the hot water temperature was 115 degrees Fahrenheit. Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged. Smoke and Carbon monoxide detectors were operational. Adequate supplies of PPE were also observed stored in the garage. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/04/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/26/2022 12:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELROSE CARE HOME	FACILITY NUMBER: 075600885
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2022
	Plan of Correction
1 2 3 4	Licensee will: (1) discard all uncovered food, (2) date all undated food, and (3) prominently display a written reminder, "IMPORTANT: REMEMBER TO WRITE DATE OPENED ON ALL FOOD PACKAGING" on every refrigerator and freezer in the facility. Administrator will send pictures as proof to the LPA before the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

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