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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610085
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:15:34 PM

Document Has Been Signed on 11/17/2022 03:15 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELVOIR HOME ADULT RESIDENTIALFACILITY NUMBER:
197610085
ADMINISTRATOR:REYES, SHARON ROSE PFACILITY TYPE:
735
ADDRESS:9337 BELVOIR AVE.TELEPHONE:
(818) 468-6831
CITY:LA CRESCENTASTATE: CAZIP CODE:
91214
CAPACITY: 4CENSUS: 3DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Sharon Reyes, AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year Infection Control inspection to the facility. LPA met with Administrator Sharon Reyes and explained the reason for the visit.

A tour of the physical plant was conducted at 01:15 pm and the following was noted:

There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, and masks are available.
The facility had submitted and approved Mitigation Plan.

Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area in the backyard. The facility has sufficient stock of PPE in the garage.

The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (03) residents. All rooms are private rooms.

(continued on LIC 809-C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELVOIR HOME ADULT RESIDENTIAL
FACILITY NUMBER: 197610085
VISIT DATE: 11/17/2022
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Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 76 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguisher is located in the kitchen and was last purchased in October 2022.

The backyard of the facility has outdoor furniture with a covered shaded area for residents. There is no body of water at the facility. There is also a garage that is being being used to store PPE.

Laundry area is located inside the garage,

Food Service/Kitchen area was sufficiently stocked seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system.

The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured at 120.0 degrees. There was enough clean linen available in stock in the closet.

There were one ( 1) complete first aid kit.

Exit interview conducted. A copy of this report was issued and signature obtained.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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