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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700947
Report Date: 12/24/2020
Date Signed: 12/24/2020 10:20:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:BELHAVEN ESTATEFACILITY NUMBER:
342700947
ADMINISTRATOR:BROOKS, DANIELFACILITY TYPE:
740
ADDRESS:9048 ELM AVETELEPHONE:
(831) 801-4626
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: DATE:
12/24/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Daniel Brooks, Monica BrooksTIME COMPLETED:
10:20 AM
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Component II completion: Successful

Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: Daniel Brooks, Monica Brooks
Interview Method: Telephone interview

On 12/24/2020, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Susan NguyenTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2020
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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