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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800652
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:24:33 PM

Document Has Been Signed on 10/03/2024 03:24 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: 6DATE:
10/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Assistant Manager, Sergio Spikes, and House Manager, Yvette MorganTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Assistant Manager, Sergio Spikes. Administrator, Yvette Morgan, arrived during visit at approximately 9:40AM. 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 5 clients out of the facility with attending Day Program and two staff members on-site.

At approximately 9:30AM, 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 reviewed staff files, client files, client medications and P&I monies. Files were all found to be well organized and thorough. Staff files had current First Aid and CPR certification. Medication was centrally stored and secure. P&I monies were documented, secure and not commingled. During staff file review, LPA observed that 1 of 6 staff members did not have annual training as required. Per facility's plan of operations, staff members should have at least 24 hours of training per year (deficiency cited and civil penalty issued, see LIC809D and LIC421FC, regulation 80022(k)). LPA and House Manager discussed how they will ensure staff members receive their 24 hours of annual training each year by their identified employment date.

LPA requested the following documents to update facility file:
  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Surety Bond (LIC 402)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELLE HOUSE
FACILITY NUMBER: 216800652
VISIT DATE: 10/03/2024
NARRATIVE
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Continued from LIC809

Documents to be submitted to Community Care Licensing (CCL) by due date of 11/03/2024.

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.

***An immediate civil penalty assessment in the total amount of $250.00 has been issued for a repeat violation of Regulation 80022(k) in more than once in a 12 month period.*** (See LIC421FC)

Exit interview conducted. Copy of report, LIC809D, LIC421FC, Plan of Corrections, and Appeal Rights discussed and provided to House Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2024 03:24 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 10/03/2024 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(k)
80022 Plan of Operation: (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee did not comply with the section cited above. Licensee did not ensure that facility staff received their 24 hours of annual training as stated in their Plan of Operation. LPA identified that 1 of 6 staff members did not have their 24 hours ofannual training completely timely. This poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee agrees to submit an updated and detailed plan on how they will ensure staff members receive their annual training each year by their employment date. Licensee to also submit proof of completed training for all facility employees hired prior to 2024. Plan and staff trainings to be submitted to CCL by POC due date of 10/14/2024.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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