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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800652
Report Date: 07/15/2026
Date Signed: 07/15/2026 01:54:22 PM

Document Has Been Signed on 07/15/2026 01:54 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: 5DATE:
07/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Staff Members, Deja Compton and Renante Petit-ton; Administrator, Yvette Morgan, House Manager, Randall Dunn, and Executive Director, Kate O'Connor.TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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At approximately 8:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Members, Deja Compton and Renate Petit-ton. Administrator, Yvette Morgan, Executive Director, Kate O'Connor, and House Manager, Randall Dunn, arrived during visit at approximately 9:40AM, 9:50AM, and 10:05AM. Executive Director left facility at approximately 10:45AM, and Administrator left facility at approximately 11AM. 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 5 clients in care. Four clients were out of the facility attending Day Program with 1 client on-site and two staff members on-site.

At approximately 9:00AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with House 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. Facility fire extinguishers were last inspected April 2026. Facility was observed to have an adequate supply of emergency water accessible in the event facility needed to shelter in place for 72 hours.

During walkthrough, LPA observed that facility had multiple instances of expired foods including bread, canned goods, and boxed meals/mixes such as macaroni and cheese, red beans and rice, and potato latke mix.

LPA followed up on incident reports that were submitted to the Santa Rosa Regional Office (SRRO):

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/15/2026
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Continued from LIC809

Incident Report 1: The SRRO received a report on 09/22/2025. Report stated that on 09/22/2025, Client 1 (C1) left the facility while staff members were with other clients. C1 was located at a neighbor's house. Facility staff redirected C1 back to the facility and C1 went to their scheduled Day Program. Facility made all appropriate notifications per regulation.

Review of C1's file showed that they are unable to leave the facility unassisted per their Physician Report/medical is assessment dated 07/13/2021 and their Individualized Service Plan (ISP) dated 07/19/2025. Per medical assessment, C1 is unable to leave facility unsupervised. Per ISP, C1 is at a moderate risk to elope and facility staff should maintain visual contact at all times.

Incident Report 2/SOC-341: The SRRO received a SOC-341 report and supplemental incident report on 07/13/2026. Per reports, on 07/11/2026, Staff Member 1 (S1) observed an incident between Staff Member 2 (S2) and Client 2 (C2). Report stated that S1 observed S2 push C2 while shaving them with Staff Member 3 (S3). Per reports, S2 also grabbed and squeezed C2's face. C2 sustained superficial scrapes on their arm from the chair and first aid was applied with no serious injuries. C2 was noted to return to their normal routine following the incident. Facility made all appropriate notifications per regulation.

Reports further stated that S2 was suspended pending internal investigation.

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

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. Copy of report, Plan of Corrections, Appeal Rights discussed and provided to House Manager. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/15/2026 01:54 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 07/15/2026 at 12:55 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: 07/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. It was observed that faciity had multiple instances of expired food items, including snacks, bread, and boxed meals/mixes, and canned goods. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2026
Plan of Correction
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Licensee to submit a written plan on how they will ensure that facility food is stored in a safe and healthful manner. Written Plan to be submitted to Community Care Licensing by POC due date of 07/27/2026.
Type B
Section Cited
CCR
85078(a)(1)
85078 Responsibility for Providing Care and Supervision: (a) In addition to Section 80078, the following shall apply:
(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review, Licensee did not comply with the section cited above. Client 1 (C1) eloped from the facility and was located at a neighbor's house. C1's medical assessment and Individualized Service Plan (ISP) state C1 is unable to leave facility unassisted, and requires constant supervision. This poses a potential health/safety/personal rights risk to clients in care.
POC Due Date: 07/27/2026
Plan of Correction
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Licensee to submit proof of elopement training for all direct care staff. Training to include topic, date of training, staff names and titles, staff signatures, and any supporting documents. Documents to be submitted to CCL by POC due date of 07/27/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2026


LIC809 (FAS) - (06/04)
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