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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700946
Report Date: 01/27/2021
Date Signed: 01/27/2021 02:51:28 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:BELHAVEN ESTATE IIFACILITY NUMBER:
342700946
ADMINISTRATOR:BROOKS, DANIELFACILITY TYPE:
740
ADDRESS:9046 ELM AVETELEPHONE:
(831) 801-4626
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 0DATE:
01/27/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Daniel and Monica BrooksTIME COMPLETED:
02:30 PM
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 (LPA) Wolter conducted a prelicensing inspection via tele-visit with administrators Daniel and Monica Brooks on 01/27/2021 due to COVID-19 and precautionary measures. The facility has an approved fire clearance for six (6) non-ambulatory residents, LPA observed no residents in care at time of inspection.

Administrators and LPA toured the facility via video conferencing and observed the following areas: six (6) resident bedrooms with half baths, shower room, common areas, laundry and medication room, garage, and outdoor space. The facility appeared to be in good repair at time of inspection and equipped with smoke and carbon monoxide detectors throughout the home. LPA observed laundry and medication room to require key code entrance, knives were observed to be stored in a locked drawer. Resident bathrooms had required grab bars, shower room had required grab bar and non-slip flooring. LPA observed facility to have supply of non-perishable food items and administrators understand a 2-day supply of perishable items is to be on hand when residents are in care. Facility water heater was set to appropriate temperature between 105-120 degrees F. Fire extinguisher was serviced on 12/3/2020.

Facility will utilize care and compliance for staff training. Administrators understand that complete staff and resident records are to be kept at the facility. Copy of liability insurance was sent to LPA.

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.
Component III was waived as licensee has an existing facility in substantial compliance. LPA will contact the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application.

Exit interview conducted and copy of report was emailed to licensee, signed copy to be returned to Community Care Licensing, a signed copy should be retained for facility records.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021
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