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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700947
Report Date: 04/17/2023
Date Signed: 04/17/2023 01:24:34 PM


Document Has Been Signed on 04/17/2023 01:24 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:BELHAVEN ESTATEFACILITY NUMBER:
342700947
ADMINISTRATOR:WILSON, JENNIFERFACILITY TYPE:
740
ADDRESS:9048 ELM AVETELEPHONE:
(831) 801-4626
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
04/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Danie BrooksTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived on Monday April 17, 2023 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (6) and staff files (4). All resident files contained the required paperwork. Three (3) out of four (4) staff files did not contain complete health screening LIC503 and TB test. All staff have current first aid and CPR training. Facility was clean and well organized. All required posting were observed. Staff training contained the required initial training.

LPAs and Administrator Daniel Brooks toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. LPAs checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPAs observed cleaning products and other toxins to be locked away. LPAs observed the area used for medication to be locked and inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. In the areas toured, there were no health or safety violations observed.

LPAs requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 04/30/23.

LIC 809-D for deficiency cited during today's visit. Exit interview conducted and appeal rights provided. A copy of this report was printed and given to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
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 04/17/2023 01:24 PM - 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: BELHAVEN ESTATE
FACILITY NUMBER: 342700947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 4 staff files were missing or incomplete Heallth Screening and TB test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2023
Plan of Correction
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Licensee agrees to submit incompete staff forms to LPA by 4/25/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
LIC809 (FAS) - (06/04)
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