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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700947
Report Date: 05/17/2021
Date Signed: 05/18/2021 10:25:17 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 4DATE:
05/17/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Daniel and Monica BrooksTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility announced on 05/172021 to conduct an announced prelicensing visit. This facility is undergoing a change-of-ownership. LPA met with Daniel and Monica Brooks and explained the purpose of the visit. Prior to initiating the prelicensing visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted applicant and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Daniel Brooks.
This facility has a fire clearance for all non-ambulatory. This facility has six private resident rooms. The main entrance opens to the main common area and a kitchen. Past the kitchen and to the left is the main hallway that has a fire door leading to six private resident rooms, one large storage room, and one full common bathroom. Before the fire door there is one half common bathroom, laundry room, and one small storage room. There is an exit to the outside at the end of the hallway. The back of the main common area there is a small meeting room. Two of the resident rooms have private full bathrooms.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: BELHAVEN ESTATE
FACILITY NUMBER: 342700947
VISIT DATE: 05/17/2021
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The facility property is enclosed by a fence. There is a gate across the driveway and the code is available. Next to the gate across the driveway is a pedestrian gate that is not locked. There is a small house that is not licensed on this property. There is also a barn and small animal area.

There is a second floor that has two bedrooms and a full bathroom. There is a staircase from the inside that is not accessible to the residents.

Component three is waived due to the applicants already operating a facility.
This facility meets licensing requirements. LPA is going to submit this to applications specialist.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
LIC809 (FAS) - (06/04)
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