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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005710
Report Date: 06/10/2020
Date Signed: 06/10/2020 02:18:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BELLE VIE RESIDENTIAL ASSISTED LIVINGFACILITY NUMBER:
317005710
ADMINISTRATOR:ARAKELYAN, AMBERFACILITY TYPE:
740
ADDRESS:1422 ORWELL DRIVETELEPHONE:
(916) 742-5477
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 0DATE:
06/10/2020
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Amber RileyTIME COMPLETED:
02:10 PM
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LPA Hiratsuka, conducted this announced visit via FaceTime due to precautions taken due to Covid 19 in response to Licensee/Administrator Amber Riley stating she is closed. Licensee walked around the facility and showed LPA the empty resident rooms and the living room that was packed full of boxes.

LPA requested a signed stating from Licensee stated she is closed and the effective date of closure. LPA also advised Licensee if Licensee is able to find the facility license that she is to write the date of closure on it or destroy it.


LPA shall close the facility file in the office upon receiving the written statement from the licensee.


This report shall be emailed to Licensee for review and signature. Licensee is to sign and email a copy of the signed report to LPA.

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020
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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