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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881214
Report Date: 03/03/2023
Date Signed: 03/03/2023 12:48:45 PM

Document Has Been Signed on 03/03/2023 12:48 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BELLES COURTFACILITY NUMBER:
331881214
ADMINISTRATOR:ANCHONDO, JESSICAFACILITY TYPE:
735
ADDRESS:6770 CONDOR DRTELEPHONE:
(323) 945-5605
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY: 4CENSUS: 1DATE:
03/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Christian, AdministratorTIME COMPLETED:
11:20 AM
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, Amber Coleman (LPA) arrived unannounced to the Belle's Court Adult Residential Facility to conduct an annual inspection. LPA introduced self and stated the purpose of the visit. LPA was greeted and granted entry by Christian Castellanos, Administrator. Upon entry, LPA was informed the facility had admitted it's first resident 2 days prior to visit on 3/1/23. LPA observed resident engaged in activities in the living area of the facility. LPA was provided a walk through of the physical plant and space to work. Administrator Stephanie Castellanos, arrived later during the visit.

Personnel Records/Training/and Staffing- LPA reviewed of employee records. One (1) records were reviewed. LPA reviewed employee record for first aid certification, finger print clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification.

Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA began review of resident records. One (1) record was reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, weight chart, face sheet and personal rights notification.

Food Service- LPA observed adequate amounts of food for the resident in care. The food available is adequate to meet the nutritional needs of the resident. Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables food on hand.

At approximately, 10:45AM LPA and Administrator tested the temperature of the water at 130 degrees Fahrenheit. Administrator addressed matter by posting notification warning of hot water temperatures and turning the water heater temperature down.

Technical violations (TV's) being issued for aforementioned concerns due to the temperature of the water. An exit interview was conducted where this report and LIC9102TV were discussed and provided to the Administrator.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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 1