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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005820
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:58:07 PM

Document Has Been Signed on 08/29/2024 03:58 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BELGREEN MANORFACILITY NUMBER:
306005820
ADMINISTRATOR/
DIRECTOR:		ALMACEN, VOLTAIREFACILITY TYPE:
735
ADDRESS:24761 BELGREEN PLTELEPHONE:
(949) 288-3355
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 3CENSUS: 3DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Delwyn Lacson, licenseeTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility licensee Delwyn Lacson after introducing himself and stating the reason of the visit.

During the inspection, LPA and licensee conducted a tour of the physical plant and observed the following: The facility is a one story home with three private client bedrooms and one shared bathroon in addition to the facility's common living areas, staff living quarters and an attached garage. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. There are no postural supports in use currently.

There are currently three clients admitted to the facility, with two clients present during the visit. A third client was a work when the visit was conducted. One of the three current clients is also pending new placement from the Regional Center of Orange County due to his need for a higher level of care. Bathrooms faucets and toilets are operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Fire and emergency drills have been conducted regularly.

LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are observed to be fully charged with up-to-date maintenance tags.

There is ample shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the house and routes of egress are free of obstructions. There are no bodies of water on the premises.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BELGREEN MANOR
FACILITY NUMBER: 306005820
VISIT DATE: 08/29/2024
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CONTINUED FROM FORM LIC809
Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed three client files and three staff files. Client records include all necessary components. All staff members are confirmed to be cleared and associated with this particular licensed location, with current first aid and CPR training. One client and one staff interviews conducted during the visit.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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