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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800652
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:37:00 PM

Document Has Been Signed on 08/20/2024 02:37 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BELLE HOUSEFACILITY NUMBER:
216800652
ADMINISTRATOR/
DIRECTOR:
YVETTE MORGANFACILITY TYPE:
735
ADDRESS:865 BELLE AVENUETELEPHONE:
(415) 457-9632
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 6CENSUS: DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Assistant Manager, Sergio SpikesTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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At approximately 11:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Assistant Manager, Sergio Spikes. Administrator, Yvette Morgan, was available by telephone. 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 four clients out of the facility with attending Day Program and two staff members on-site.

At approximately 12:00PM, 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 12:10PM, LPA conducted a walk-though of the facility with Assistant Manager. LPA observed the following: 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, and common areas. Facility has an Infection Control 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.

LPA reviewed staff and client files. Administrator's Certificate for Yvette Morgan (7031272735) was current with an expiration date of 07/19/2025. Fire extinguishers were last inspected April 2024. Smoke detectors and carbon monoxide detectors were tested and operational. The last facility fire/disaster drill was conducted in July 2024.

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



No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Assistant Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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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