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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803702
Report Date: 06/21/2022
Date Signed: 06/21/2022 11:12:32 AM

Document Has Been Signed on 06/21/2022 11:12 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
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:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Bessa Livica, AdministratorTIME COMPLETED:
11:22 AM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Bessa Livica, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility for Persons with Special Health Care Needs.
LPA conducted a tour with on duty nurse Rhine Melido of the facility which was observed clean and at a comfortable temperature. All exits were unobstructed. The facility has a screening station (hand sanitizer, a thermometer, COVID questionnaire, and a sign-in sheet for visitors and staff). LPA was screened for COVID-19 symptoms and temperature was taken and documented. Staff verify visitor's vaccination status or a negative COVID test as required for indoor visitation. Staff clean and disinfect the facility and high touched surface areas twice per shift and after use. The facility has a designated visitation area, provides virtual visits and phone calls for visitors to stay in contact with clients. Staff and client's temperatures are taken and documented daily 2 times per shift (every 4 hours, unless their condition has changed). LPA observed clients participating in activities. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. Facility staff have completed training on PPE use, isolation policies, and infection prevention. LPA observed a binder with monthly staff protocol related to mitigating COVID-19. N-95 respirator Fit testing for staff (Cal/OSHA requirement) has been completed. LPA observed a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. All staff wore a face mask during this visit. LPA verified staff's vaccination status for COVID-19; all staff have completed and have documentation in their files.
LPA requested the following updated forms to be submitted to Community Care Licensing by 07/11/2022:
· 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)
· LIC 402 Surety Bond
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
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: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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