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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294196
Report Date: 09/09/2022
Date Signed: 09/09/2022 04:04:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/09/2022 04:04 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
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:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Ravenal CruzTIME COMPLETED:
02:07 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manger (HM) Ravenal Cruz . Upon arrival, HM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with HM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, gloves, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towel were observed with holder. Three shared resident bedrooms, and laundry room were inspected. Two staff live-in rooms are in facility. There were posters of washing hands for 20 seconds were observed by the sinks in kitchen and restrooms. Cloth towels were observed in kitchen and restrooms. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 75 degree F, and hot water temperature was at 108 degree F in facility. 4 residents and 3 staff were observed in facility.

Fire extinguisher was serviced on 11/08/2021. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

HM stated all the residents and staff are fully vaccinated and done with booster. The facility already submitted the Infection Control Plan. LPA checked the resident file binders. The resident file binders are up to date.

No deficiency or citation were noted today. Exit interview was conducted with HM. This report was provided to HM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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