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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800652
Report Date: 08/05/2022
Date Signed: 08/05/2022 04:33:52 PM

Document Has Been Signed on 08/05/2022 04:33 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:SMITH, SHAQUILAFACILITY TYPE:
735
ADDRESS:865 BELLE AVENUETELEPHONE:
(415) 457-9632
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 6CENSUS: 6DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Direct Support Provider, Lushell FrazierTIME COMPLETED:
04:45 PM
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At approximately 2:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-year required Annual Visit and met with Direct Support (DSP), Lushell Frazier. Administrator, Shaquila Smith, was available by telephone, and gave permission for DSP to sign report. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. Hand Sanitizer was readily available for use throughout the facility. Toxins and detergents were secured and inaccessible to residents. Medications were located in the medication cabinet that was locked and inaccessible to residents. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

LPA and Administrator discussed facility's plan for staffing if a shortage occurred.

Facility has a cleaning and disinfecting schedule that occurs two to three times per shift. Facility has at least a 30-day supply of PPE and medication for clients. Staff and clients are screened daily for COVID-19 symptoms and it is logged into facility binders.

Fire Extinguishers were last serviced July 2022. Carbon Monoxide detector were tested and operational. LPA observed that 2 of 4 Smoke Detectors were out of operation due to the batteries being taken out and not being replaced. Per conversation with DSP, one of the clients took the batteries out and they were not put back in. LPA and Administrator discussed the importance of ensuring batteries are placed back into the detectors.

Continued on LIC-809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELLE HOUSE
FACILITY NUMBER: 216800652
VISIT DATE: 08/05/2022
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Continued from LIC-809

During walk-through, LPA observed that one of the client windows was boarded up. The window frame was outside on the ground. Pictures taken.
LPA and Administrator discussed getting the window fixed. Administrator stated that three weeks ago, a client got upset and pushed the window out. Facility has been in contact with repair company to get it replaced.

LPA and Administrator discussed PIN-22-13-ASC regarding Infection Control Plans.

LPA Felias requested the following documents to update facility file:
  • Administrative Organization (LIC 309)
  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Control of Property
  • Emergency Disaster Plan (LIC 610D)
  • Facility Sketch/Floor Plan (LIC 999)
  • Personnel Report (LIC 500)
  • Surety Bond (LIC 402) if applicable

Documents requested to be submitted by Close of Business on Friday, September 2, 2022.

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.

Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC
9099-D, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2022 04:33 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 08/05/2022 at 03:53 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: 08/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)

80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the facility failed to ensure that all smoke detectors were functioning. 2 of 4 detectors tested were not working due to the batteries being taken out and not replaced. LPA observed a client window that was boarded up with the window frame outside on the ground. This poses an immediate health and safety risk to clients in care.
POC Due Date: 08/06/2022
Plan of Correction
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Licensee to submit self-certification that the batteries will be replaced in the smoke detectors, and that the window repair will be scheduled by POC 8/6/2022. Licensee to submit a plan to ensure that smoke detector batteries will be checked on a frequent basis to ensure detectors are operable by POC date 8/26/2022. Licensee to submit proof of invoice/receipt of window repair, and send proof of window fix by POC date 8/26/2022.
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: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022


LIC809 (FAS) - (06/04)
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