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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075600885
Report Date:
12/28/2022
Date Signed:
12/28/2022 03:58:45 PM
Document Has Been Signed on
12/28/2022 03:58 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:
12/28/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:45 AM
MET WITH:
Rosa Junsay
TIME COMPLETED:
04:30 PM
NARRATIVE
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On 12/28/2022, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection, and explained purpose of the visit to staff upon entry who called administrator
Rosa Junsay
. LPA inspected the facility inside and out and observed the 2 live-in staff members interacting with and caring for all of the 5 clients in a caring and professional manner.
Though they have an infection control plan in place, facility cited for not following it or the latest COVID-19 infection control guidance. Infection control designated leader is
Rosa Junsay
. They have one central entry point at the front entrance with a visitor's log, hand sanitizer and no touch temperature probe and COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. However, they were not following guidance.
There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed. Facility room temperature was maintained at 74.1 degrees Fahrenheit. Fire extinguisher fully charged and serviced 10/20/2022. Smoke detectors operational, but not carbon monoxide detector. Administrator is on site a minimum of 20 hours a week to oversee proper business operation.
Continued on LIC809-D . . .
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
12/28/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
8
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:
12/28/2022
NARRATIVE
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. . . Continued from LIC809
Facility cited for:
COVID-19 violations: not 30 day supply of PPE; staff, residents, and visitors not wearing masks; cloth towels being used in shared bathroom; and allowing visitors to enter without staff conducting COVID-19 checks.
Toxic chemicals were stored in unlocked bathroom drawer and closet
Unlocked outside sheds with paint, toxic chemicals, and tools.
Unlocked drawer in kitchen with 2 sharp knives.
Hot water dangerously high at 130 degrees Fahrenheit.
Auditory device on exterior door in Bedroom #6 not working.
Unlocked centrally stored medication cabinet.
Emergency / Disaster Plan with wrong staff, inadequate emergency water supply, and no quarterly drills having been done since April 2022.
Carbon monoxide detector not working.
Side gate locked shut.
Administrator to send updated copies of these documents to CCL on or before 01/05/2023:
LIC500 - Personnel Report
LIC308 - Designation of Facility Responsibility
LIC610D - Emergency/Disaster Plan
Evidence of sufficient Liability Insurance
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:
12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2022
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
12/28/2022 03:58 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:
12/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
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 in 1 of 1 detectors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/29/2022
Plan of Correction
1
2
3
4
Corrected during inspection.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
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, the hot water was measured at 130 degrees, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/29/2022
Plan of Correction
1
2
3
4
Reduce hot water temperature to safe range and attest to LPA that has been accomplished on or before due date.
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:
12/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2022
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
12/28/2022 03:58 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:
12/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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 with toxic chemicals were stored in unlocked bathroom drawer and closet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/29/2022
Plan of Correction
1
2
3
4
Completed during inspection.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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 in 1 of 1 medicine cabinets by leaving the key in the lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/29/2022
Plan of Correction
1
2
3
4
Completed during inspection.
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:
12/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2022
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
12/28/2022 03:58 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:
12/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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 in unlocked drawer in kitchen with 2 sharp knives which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/29/2022
Plan of Correction
1
2
3
4
Corrected during inspection.
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:
12/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2022
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
12/28/2022 03:58 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:
12/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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 concerning COVID-19 violations (not 30 day supply of PPE; staff, residents, and visitors not wearing masks; cloth towels being used in shared bathroom; and allowing visitors to enter without staff conducting COVID-19 checks) which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/05/2023
Plan of Correction
1
2
3
4
Licensee shall: (1) review COVID-19 PINs with staff and update facility policies to align with the guidance and (2) purchase 30-Day supply of PPE. Licensee shall send email to LPA attesting to having completed the training and the updated facility policies on or before the POC due date.
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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 concerning unlocked outside sheds with paint, toxic chemicals, and tools which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/04/2023
Plan of Correction
1
2
3
4
Completed during inspection.
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:
12/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2022
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
12/28/2022 03:58 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:
12/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
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 concerning the Emergency / Disaster Plan with wrong staff, inadequate emergency water supply, and no quarterly drills having been done since April 2022 which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/04/2023
Plan of Correction
1
2
3
4
Licensee shall: (1) update Emergency / Disaster plan with correct staff and ensure the plan is complete, (2) purchase and label water as being for emergency use only, and (3) conduct quarterly emergency drill and put into facility calendar time for those drills on an ongoing basis. Licensee shall send email to LPA attestating to and providing proof that the task has been completed on or before the POC due date.
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.
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 because both of the gates are not self-latching and they were either locked or locking which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/12/2023
Plan of Correction
1
2
3
4
Licensee shall: (1) repair both gates by removing locks and locking handles and mechanisms and (2) install fully functioning self-latching mechanisms. Licensee shall send email to LPA attestating to and providing proof that the task has been completed on or before the POC due date.
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:
12/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2022
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
12/28/2022 03:58 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:
12/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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 concerning exterior door in bedroom #6 which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/04/2023
Plan of Correction
1
2
3
4
Licensee shall install or repair audiotry device in bedroom #6. Licensee shall send email to LPA attestating to and providing proof that the task has been completed on or before the POC due 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:
12/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2022
LIC809
(FAS) - (06/04)
Page:
8
of
8