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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601320
Report Date: 04/18/2022
Date Signed: 04/26/2022 01:41:35 PM


Document Has Been Signed on 04/26/2022 01:41 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 IIIFACILITY NUMBER:
075601320
ADMINISTRATOR:JUNSAY, ROSAFACILITY TYPE:
740
ADDRESS:226 NORMANDY LANETELEPHONE:
(925) 689-8831
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rosa JunsayTIME COMPLETED:
03:00 PM
NARRATIVE
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On 04/18/2022 at 10:00 AM, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced infection control and required one year inspection. Upon arrival, LPA was greeted by staff S1. LPA explained the purpose of the visit to S1 and toured the facility inside and outside. Director Rosa Junsay arrived at 10:45 AM and toured the facility with the LPA.

LPA observed staff wearing face masks during visit and their use of a visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe for screening. LPA observed COVID-19 signs posted in common areas to promote hand washing, cough/sneeze etiquette, and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks.

During the visit, pathways were observed to be free of obstruction and fire hazards. Last Fire drill was conducted in February 2022 for which Ms. Junsay will send electronic proof to LPA by 04/19/2022.. Facility room temperature was maintained at a comfortable 68.7 degrees Fahrenheit and the hot water temperature was 111 degrees Fahrenheit.

The facility was cited for the numerous physical plant updates and repairs needed. Additionally, Licensee will send the following by 04/19/2022 to LPA:
  • Copy of Quarterly Emergency Disaster Drill log
  • Personnel Report (LIC500)

Exit interview conducted and a copy of this report was provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
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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Document Has Been Signed on 04/26/2022 01:41 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 III
FACILITY NUMBER: 075601320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2022
Plan of Correction
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Send proof of completed updates and repairs: (1) updated facility sketch with fence (2) pieces of wood and other junk in back and side yard removed (3) removal of dryer from temporary location in back of facility (4) replace trash bins so that ALL have functioning tight fitting lids (5) lock all outside storage, and (6) repair fence board.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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