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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202571
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:45:43 PM


Document Has Been Signed on 09/22/2023 04:45 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:BELLEROSE SENIOR LIVINGFACILITY NUMBER:
435202571
ADMINISTRATOR:LORI CORRALFACILITY TYPE:
740
ADDRESS:100 BELLEROSETELEPHONE:
(888) 324-6520
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:26CENSUS: 17DATE:
09/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Lori CorralTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit. LPA met with Administrator, Lori Corral.

On 08/21/2023, the Department received an incident report regarding resident (R1) who was sent to the hospital after testing positive for an infectious disease. The Department also received death reports for resident (R2) – (R3) who were positive for an infectious disease at the time of passing.

Upon following-up with the facility, the Department was informed the facility had an infectious disease outbreak that started on 08/06/2023. The Department was not informed of the outbreak until 08/21/2023.

Administrator stated she had left a voicemail for our Department between 08/08/2023 08/10/2023 however, could not recall who she had left a voicemail for. A written incident report was not sent to our Department until 08/21/2023.

The facility was in contact with the Local Public Health Department during their infectious disease outbreak period.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Administrator, Lori Corral and Medication Technician Odalys Rodriguez a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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 09/22/2023 04:45 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: BELLEROSE SENIOR LIVING
FACILITY NUMBER: 435202571

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2023
Section Cited
CCR
87211(a)(2)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by:
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Licensee will submit a written plan regarding reporting infecious disease outbreaks to the Department by POC due date of 09/23/2023.
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Based on interview, record review, and observation the licensee did not ensure to report their infectious disease outbreak to the Department within 24 hours which poses/posed an immediate health, safety, and personal rights risk to persons 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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