347001685-1-28-2025-27-AS-HWIS-DCWSAR-20250114124245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001685
Report Date: 01/14/2025
Date Signed: 01/28/2025 10:16:37 AM

Document Has Been Signed on 01/28/2025 10:16 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	BELLE'S CARE HOME		FACILITY NUMBER:	347001685
ADMINISTRATOR/ DIRECTOR:	BALBUENA,EVELIO		FACILITY TYPE:	735
ADDRESS:	3430 EASTERN AVENUE		TELEPHONE:	(916) 489-7657
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY: 6		CENSUS: 4	DATE:	01/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:56 AM
MET WITH:	Maebelle Balbuena		TIME VISIT/ INSPECTION COMPLETED:	12:45 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) Holly Williams and Licensing Program Manager (LPM) Liza King arrived unannounced to conduct an annual inspection. LPA Williams and LPM King met with facility designee Maebelle Balbuena and explained the purpose of the visit. Balbuena is filling in for the licensee/ Administrator because the licensee/Administrator is out of the country. Balbuena gave LPA Williams a LIC308 Designation of Facility Responsibility. LPA Williams reminded designee that this is a reporting requirement. LPA Williams and LPM King reviewed four resident files (R1-R4) and three staff files (S1-S3). LPA Williams toured the facility with Balbuena and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 114.1 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Williams observed a knife in the dishwasher and asked where they keep the knives and S1 stated that they keep them in the unlocked staff room. LPA Williams observed the staff room unlocked and observed prescription medication out on the dresser. LPM King found two saws in the garage unlocked. A review of residents cash resources (P&I) was conducted today during todays annual inspection. R1 has no documented deposits during the month of December and January 2024 and forwarded balance do not equal cash on hand. R2 has no deposits for January 2025 and forwarded balances do not match cash on hand. R3 had no deposits for November, December, or January and forwarded balances do not match cash on hand. R4 had no deposits for December and January and forwarded balances do not match cash on hand. LPA Williams and LPM King observed that R3 and R1 did not have current IPP's Balbuena stated that they would be emailed to LPA Williams. [Continued on 809-C]

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELLE'S CARE HOME	FACILITY NUMBER: 347001685
	VISIT DATE: 01/14/2025

NARRATIVE

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Additionally a review of client P&I does not appear to show any restaurant or small store purchases from outings during the months of Nov, Dec and current month. A discussion with the designee reports that clients go out for shopping/eating on weekends however designee was not able to provide documentation of these outings. Technical Assistance provided. LPA Williams observed that two of four client files are over 60 and 1 other client will turn 60 in 2 years. Technical Assistance was provided to the designee and a functional assessment was printed and provided to designee.

LPA Williams and LPM King observed first aid supplies, a fully-charged and upto date fire extinguisher. LPA Williams and LPM King observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Williams and LPM King observed a locked cabinet for the storage of medication.

LPA Williams and LPM King interviewed 2 staff member (S1-S2) and three resident (R1-R3).

This facility is being cited per 22 CCR Section 80087(g) and 80026(h)(1) . An exit interview was held with Balbuena. Appeal rights and a copy of this report were given to Balbuena

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/28/2025 10:16 AM - It Cannot Be Edited

Created By: Holly Williams On 01/14/2025 at 12:08 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELLE'S CARE HOME	FACILITY NUMBER: 347001685
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not lock up their kinives or the staff room with medication in it which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	Licensee agrees to make sure the staff room is locked and once the staff is done using the knife it will be put back in the locked staff room. Please send statement outlining time and date of training on locking up medications and knives by POC due date. Licensee agress to send when training is complete to send sign in sheet to LPA Williams email holly.williams@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Czarrina A Camilon-Lee

LICENSING EVALUATOR NAME:

Holly Williams

LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/28/2025 10:16 AM - It Cannot Be Edited

Created By: Holly Williams On 01/14/2025 at 12:08 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELLE'S CARE HOME	FACILITY NUMBER: 347001685
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80026(h)(1)

Safeguards for Cash Resources, Personal Property and Valuables

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not keep accurate balances of cash on hand which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	Licensee agrees to reconcile the P&I and provide copies to LPA Williams by POC due date. Holly.williams@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Czarrina A Camilon-Lee

LICENSING EVALUATOR NAME:

Holly Williams

LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4