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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005820
Report Date: 08/29/2022
Date Signed: 08/29/2022 10:38:51 AM

Document Has Been Signed on 08/29/2022 10:38 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BELGREEN MANORFACILITY NUMBER:
306005820
ADMINISTRATOR:ALMACEN, VOLTAIREFACILITY TYPE:
735
ADDRESS:24761 BELGREEN PLTELEPHONE:
(949) 288-3355
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 3CENSUS: 2DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Administrator - Voltarie AlmacenTIME COMPLETED:
10:48 AM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio was greeted and granted entry by staff on duty who checked temperature prior to entering facility.
NOTE: Ring doorbell/camera is located at the main entrance of the facility next to the front gate and is utilized as the main door bell.

During the visit, 2 staff were on duty, of which consisted of the facility administrator (AD) Voltarie Almacen and House Manager (HM) Delwyn Lacson. As of 8/29/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. The PUB475 "See Something, Say Something" poster was also observed at the main entrance of the facility. LPA observed the Administrator's Certificate for Voltarie Almacen which expires on 9/2/2023.

LPA De Perio toured the interior and exterior portions of the facility with HM Lacson . The facility is a single level structure and is licensed for 3 ambulatory clients. Currently, there are a total of 2 clients in care, of which client #1 was asleep and client #2 was attending day program. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detectors were tested and operational. The restrooms were observed to be in good repair, toilets were operational and water temperature in restrooms were measured to be at 105.1 degrees Fahrenheit and hand washing signs were also posted in each restroom
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BELGREEN MANOR
FACILITY NUMBER: 306005820
VISIT DATE: 08/29/2022
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients in care. Fire extinguisher was charged and located in the kitchen.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 exit gates in the backyard, which both were self-closing and self-latching. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen. Facility had back-up emergency food and water supply, located in the garage and hallway closet. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in hallway closet. Medications were locked and located in the laundry room and were inaccessible to clients in care. Toxins were also observed to be locked and inaccessible to clients.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Almacen and HM Lacson. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio discussed with AD Almacen and HM Lacson to review and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio advised both AD Almacen and HM Lacson to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Almacen and HM Lacson and a copy of this report was provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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