075601028-4-26-2022-15-AS-JSAR-CDUNJF-20220426103017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601028
Report Date: 04/26/2022
Date Signed: 04/26/2022 10:32:25 AM

Document Has Been Signed on 04/26/2022 10:32 AM - 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 II		FACILITY NUMBER:	075601028
ADMINISTRATOR:	JUNSAY, ROSA C.		FACILITY TYPE:	740
ADDRESS:	36 BAI GORRY PLACE		TELEPHONE:	(925) 932-8822
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 6	DATE:	04/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Rosa Junsay		TIME COMPLETED:	11:00 AM

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 8:15AM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with S1 upon entry, who then called the administrator who arrived at 9:50AM. 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 assisting 4 of the 6 clients with activities of daily living. 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. 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 inside the garage. 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 II	FACILITY NUMBER: 075601028
	VISIT DATE: 04/26/2022

NARRATIVE

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All staff and 6 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.

Facility room temperature was maintained at 68.2 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

No deficiencies cited during this visit. 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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