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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803702
Report Date: 06/20/2023
Date Signed: 06/20/2023 02:24:22 PM

Document Has Been Signed on 06/20/2023 02:24 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BELEN HAVEN IFACILITY NUMBER:
486803702
ADMINISTRATOR:LIVICA, BESSAFACILITY TYPE:
734
ADDRESS:3840 STAFFORD SPRINGS WAYTELEPHONE:
(650) 580-3896
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 5DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bessa Livica, AdministratorTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and met with Bessa Livica, Administrator.
LPA toured the facility, all exits were unobstructed. The facility was found to be clean & at a comfortable temperature. LPA observed a supply of PPE, emergency supplies, linens (bedding, towels, etc.), and cleaning solutions (observed locked). Liquid hand soap and paper towels are available in 2 of 2 bathrooms. Client's bedrooms were fully furnished per regulation. Medication was centrally stored. Water temperature was tested and observed between 105 to 120 degrees F as required.
Quarterly Disaster Drills are conducted on a monthly basis. Fire extinguisher were charged and serviced 08/30/2022. There are 12 hardwired combination smoke & carbon monoxide detectors were observed operational. LPA reviewed staff and client records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) in file. Client files are complete and up-to-date. Clients have received annual checkups for medical, dental, optometry, neurological, behavioral, and pulmonary health.

LPA requested the following updated forms to be submitted to Community Care Licensing by 07/30/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Surety Bond
· LIC 9020 Facility Register of Client/Residents
· LIC 610D Emergency Disaster Plan
· Copy of current Administrator's Certificate

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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