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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202571
Report Date: 05/22/2024
Date Signed: 05/22/2024 09:52:01 AM


Document Has Been Signed on 05/22/2024 09:52 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
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: 23DATE:
05/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Odalys RodriguezTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. Administrator, Lori Corral was contacted but was unable to immediately meet LPA during visit. LPA met with lead staff (S1), Odalys Rodriguez and S2.

The purpose of the visit is to follow-up on an incident report regarding a power outage at the facility on Tuesday, 05/14/2024. On Wednesday, 05/15/2024 the Department was informed of the facility's power outage on 05/14/2024 from approximately 9:00AM - 8:00PM, due to PG&E. The Administrator stated they had a backup generator for the kitchen that also powered the refrigerator, freezer, and stove. Residents were provided all their meals and provided care. No residents were under oxygen. All the residents were doing well and no one sustained any injuries, nor were sent to the hospital during the power outage. In addition to the emergency flood lights, the facility also opened all the blinds to bring light in the facility. All families were informed of the situation. All the residents did not need to be relocated.

During visit, LPA toured the facility with staff (S2). LPA observed all the residents in the activity room eating breakfast and being provided their medication pass. LPA observed the facility has emergency flood lights attached to the emergency exit signs, extra flashlights, and batteries. Resident bedrooms all have linens and blankets. LPA observed the emergency food supply, water, and first aid kit. LPA observed the facility has an emergency binder. LPA interviewed staff who states all the residents were doing well during the power outage. The facility did not have issues with lighting. They had extra flashlights and lanterns in case it was needed. Activities for the residents were provided during the power outage. The facility's emergency disaster plan was obtained during visit. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with staff Odalys Rodriguez and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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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