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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294196
Report Date: 08/30/2021
Date Signed: 08/31/2021 08:34:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BELLE'S HAVENFACILITY NUMBER:
435294196
ADMINISTRATOR:VALIN, ROSA BELLA I.FACILITY TYPE:
740
ADDRESS:274 CLEARPARK CIRCLETELEPHONE:
(408) 229-2945
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 5DATE:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Rosa Bella Valin, ADMTIME COMPLETED:
04:46 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Annual Inspection visit, and met with administrator (ADM) Rosa Bella Valin (RV).

Upon arrival, staff Rabenal Cruz (RC) took LPA's body temperature, asked LPA infection prevention/control questionnaires, and checked LPA in the visitor log book. LPA observed 3 resident shared rooms, 2 staff live-in rooms, and 2 restrooms. LPA observed the COVID-19 posters in the facility. LPA observed 3 staff (S1 -S3) and 5 residents (R1 - R5) in the facility. Living room, kitchen, and dining area were inspected. Not all the trash cans with covers, and not all the paper towels with holders. ADM stated the facility will fix that in two days.

LPA observed all the staff wore masks. LPA inspected the food supplies. 2 day perishable foods and 7 day non-perishable foods were observed sufficient. PPE supplies were observed sufficient. Medication cabinet was observed locked. Knives were observed locked. Detergents were observed locked.

ADM stated all the staff and residents except one resident were fully vaccinated. LPA discussed LIC808 with ADM.

No citation was issued during today's inspection. Exit interview conducted with ADM. This report was provided to ADM to review and to sign. A copy of this report was emailed to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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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