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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800652
Report Date: 08/25/2023
Date Signed: 08/25/2023 03:49:17 PM

Document Has Been Signed on 08/25/2023 03:49 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BELLE HOUSEFACILITY NUMBER:
216800652
ADMINISTRATOR:ANTYON LIGGINSFACILITY TYPE:
735
ADDRESS:865 BELLE AVENUETELEPHONE:
(415) 457-9632
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 6CENSUS: 6DATE:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Staff Member, Rudy Kalandros, Manager of Program Operations, Kayla Hotchkiss, and Program Manager, Yvette MorganTIME COMPLETED:
03:55 PM
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At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Rudy Kalandros. Kayla Hotchkiss, Manager of Program Operations, arrived at approximately at 10:35AM. Program Manager, Yvette Morgan, arrived at approximately 1:30PM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed that there were 6 clients in care, with 4 clients out of the community. LPA was also informed there were currently 2 staff members on site.

At approximately 9:35AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:45AM, LPA conducted a walk-though of the facility with Staff Member. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 5 Client bedrooms, 2 1/2 bathrooms, 1 staff office, a kitchen, dining room, living room, medication area, and laundry area. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for Client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.
Facility's fire extinguishers were last inspected May 2023. The last Emergency/Fire Drill was conducted August 2023.

At approximately 10:30AM, LPA reviewed 6 Client Files. During review, LPA observed Client 1 (C1) did not have a physician's report on file, but medical appointment documentation indicated that they had a physical completed earlier this year. Facility was unable to locate the document during visit (see Technical Violation, LIC9102, Regulation 80069).

At approximately 11:55AM, LPA and Manager of Program Operations reviewed P&I Monies. Facility currently handles P&I for 5 of 6 clients. LPA observed that 3 of 5 Client P&I balances and ledgers did not match (This Deficiency has been cited, see LIC809D, Regulation 80026(h)).

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELLE HOUSE
FACILITY NUMBER: 216800652
VISIT DATE: 08/25/2023
NARRATIVE
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Continued from LIC809

At approximately 1:50PM, LPA reviewed a sample size of 6 staff files. Review of staff files indicated that 3 of 6 staff members had expired first aid certifications. Per Title 22 Regulations, staff providing direct care and supervision shall receive First Aid training from qualified agencies (This Deficiency has been cited, see LIC809D, Regulation 80075(f)).
All other staff paperwork was shown to be well organized, thorough and contained the required documentation.

LPA was informed that the current Facility Administrator is Antyon Liggins. House Manager, Yvette Morgan, is to be the Facility Administrator once their training is completed.
Facility understands that Administrator paperwork for Yvette Morgan needs to submitted to the Department when the Administrator change occurs.

LPA requested the following paperwork for when Facility changes Administrators:
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid/CPR Certificate
· Administrator Resume
· LIC 500 (Personnel Report)
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· Proof of TB test
· LIC 9182 (Criminal Record Exemption Transfer Request)
· LIC 508 (Criminal Record Statement)
· Copy of Driver's License or Passport that is not expired
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

LPA unable to complete Annual visit. Annual Continuation to be conducted at a later date.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELLE HOUSE
FACILITY NUMBER: 216800652
VISIT DATE: 08/25/2023
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Continued from LIC809C

Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Program Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/25/2023 03:49 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 08/25/2023 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BELLE HOUSE
FACILITY NUMBER: 216800652

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Record Review, the Licensee did not comply with the section cited above for 3 of 6 staff files and did not ensure that staff members had current First Aid and/or CPR certificates. This poses an immediate health, safety or personal rights risk to Clients in care.
POC Due Date: 08/26/2023
Plan of Correction
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Licensee to submit self certification that First Aid and CPR Training will be conducted for all direct care staff by POC due date of 08/25/2023. Licensee to ensure that at least one staff member on-site has current First Aid by 08/11/2023. Licensee submit Staff Member List and their Proof of First Aid and CPR certificates to CCL by POC Due Date of 09/04/2023.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/25/2023 03:49 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 08/25/2023 at 03:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BELLE HOUSE
FACILITY NUMBER: 216800652

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)

80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on File Review, the Licensee did not comply with the section cited above. LPA observed that 3 of 5 Client P&I monies were inaccurate. This poses poses a potential health, safety or personal rights risk to Clients in care.
POC Due Date: 09/04/2023
Plan of Correction
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Licensee to audit client cash resources to ensure its accuracy. Licensee to submit updated legers and statements to the Department by POC due date 09/04/2023.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
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