<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800652
Report Date: 03/03/2022
Date Signed: 03/03/2022 12:37:50 PM

Document Has Been Signed on 03/03/2022 12:37 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BELLE HOUSEFACILITY NUMBER:
216800652
ADMINISTRATOR:TOOTLE, MICHELLEFACILITY TYPE:
735
ADDRESS:865 BELLE AVENUETELEPHONE:
(415) 457-9632
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 6CENSUS: 6DATE:
03/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Care Giver(s), Anthony Theis, Lushell Frazier &
Manager, Andrea Jackson		TIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Belle Housel for the purpose of conducting a Case Management-Incident inspection. LPA Sarangi met with Care Giver, Anthony Theis, and was granted access into the facility. Care Giver #2 arrived at 11:05 AM. Manager, Andrea Jackson arrived at 12:15 PM.

Department learned via a Special Incident Report (SIR) that on 02/09/2022 Client #1 (C1) left the facility unassisted at 03:30 PM. C1 returned to the facility unharmed and with no assistance from staff. Clients physician's report dated for 07/13/2021 states that client is not allowed to leave facility unassisted. (see copies, LIC 809-D). Department also learned via a Special Incident Report (SIR) that on 02/24/2022 Client #1 (C1) left the facility unassisted at 08:30 AM. C1 returned to the facility unharmed and with no assistance from staff. Clients physician's report dated for 07/13/2021 states that client is not allowed to leave facility unassisted. (see copies, LIC 809-D). In addition, LPA toured the facility with Care Giver #2 and found that the facility was clean and at a comfortable temperature with exits free from obstruction. LPA observed sufficient perishable and non perishable foods. Hot water temperature measured at Title 22 acceptable regulation of 105 to 120 degrees F in client’s bathroom while touring facility. However, LPA was unable to access Client #2's room due to the room being locked and the only way to access that room is through a key that is with Client #2. LPA was also unable to access the office due to Care Giver #2 having no key to either rooms. Staff members will obtain keys for both rooms in case of an emergency.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided to Care Giver #2.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/03/2022 12:37 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 03/03/2022 at 08:07 AM
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: 03/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2022
Section Cited
CCR
80078

1
2
3
4
5
6
7
80078(a): Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Facility agrees to conduct staff training regarding elopment, wandering behaviors & C1 careplan and planned activities.
8
9
10
11
12
13
14
Based on interivews & records review, facility staff didn't comply with this section for 1of1 client which poses an immediate Health & Safety risk to clients in care. Client C1 eloped on February 09, 2022 and February 24, 2022.
8
9
10
11
12
13
14
Proof of staff training with participants signature, trainer signature, topics covered, & date of training to be submitted to CCL by 03/03/2022. Facility to submit self certification (LIC 9098) that clients will be supervised & kept safe by POC date 03/04/2022.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2