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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700946
Report Date: 11/10/2022
Date Signed: 11/10/2022 10:14:03 AM


Document Has Been Signed on 11/10/2022 10:14 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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: 5DATE:
11/10/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee- Monica Brooks TIME COMPLETED:
10:25 AM
NARRATIVE
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On 11/10/2022 at 9:00 AM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Health Checks. LPA met with facility staff, Keneisha Brown, and explained the purpose of the visit. Staff notified Licensee Monica Brooks of LPA's presence at the facility. LPA spoke to Licensee via telephone. Licensee stated she will arrive at the facility at a later time.

At 9:15 AM, LPA met House Manager, Kylie Moss. LPA and House Manager toured the facility together to ensure health and safety of residents in care. LPA toured 6 resident rooms, bathrooms, kitchen, medication room/laundry room, common living spaces, backyard and the garage area.

At 9:45 AM, Licensee arrived at the facility. LPA provided Licensee current care staff roster on Guardian. LPA observed two (2) care staff that is not associated to the facility providing care and supervision to residents in care. LPA informed Licensee that staff cannot be present at the facility providing care and supervision until properly associated.

Deficiencies cited on LIC 809-D.

Exit interview conducted and appeal rights given.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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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Document Has Been Signed on 11/10/2022 10:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: BELHAVEN ESTATE II
FACILITY NUMBER: 342700946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/14/2022
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c).

This requirement is not met as evidenced by: Based on observation and interviews,
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The Licensee will review section 87355(e)(2) Criminal Record Clearance. The Licensee will send the department Criminal Record Clearance Transfer Requests by the POC due date of 11/14/2022. Civil Penalty Assessed in the amount of $700.00
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S1 and S2 have been working in the facility for without having their criminal record clearance transfered. Per Guardian, S1 and S2 are not associated to the facility. This poses an immediate health and safety risk to resident's in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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