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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803702
Report Date: 07/02/2024
Date Signed: 07/02/2024 01:20:02 PM

Document Has Been Signed on 07/02/2024 01:20 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BELEN HAVEN IFACILITY NUMBER:
486803702
ADMINISTRATOR/
DIRECTOR:		LIVICA, BESSAFACILITY TYPE:
734
ADDRESS:3840 STAFFORD SPRINGS WAYTELEPHONE:
(650) 580-3896
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 4DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Bessa Livica, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At approximately 9:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection. No one answered the door, LPA contacted Licensee, Espi Sorongon who informed LPA that Bessa Livica, Administrator was at another facility and all clients were away. Administrator arrived to the facility at approximately 9:25 AM. Facility is an Adult Residential Facility For Persons with Special Health Care Needs (ARFPSHN) with four (4) non ambulatory clients in care. LPA was informed that 1 of 4 clients is in the hospital and 3 of 4 clients were at their Day Program.

At approximately 9:30 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility does not have at least two days of perishable food, because, currently, all clients have G-tubes and receive physician prescribed formulas as their sole source of nutrition. Facility does have one week of non-perishable foods, as well as an emergency water supply. LPA observed a supply of incontinent care pads and diapers for each of the clients. Medications were centrally stored and locked. There is a covered patio and seating area in the backyard with outdoor space for activities. LPA observed an activity schedule and a facility computer available for client use. Facility has internet available to clients in care and the phone was tested an operational.

Facility's fire extinguisher was observed charged and was last serviced March 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular monthly emergency/disaster drills, and the most recent drill was conducted June 2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated April 2021. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kit. Facility has a two backup generators.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BELEN HAVEN I
FACILITY NUMBER: 486803702
VISIT DATE: 07/02/2024
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Continued from LIC809...

At approximately 10:00 AM, LPA reviewed four (4) staff files and four (4) client files. Four (4) of four (4) staff files reviewed has the required current First Aid certificate and each has a current CPR certification as well. Each staff file reviewed had all the required paperwork except two (2) of four (4) did not have a LIC 503 - Health Screening signed by a physician and one (1) of four (4) was missing proof of negative TB results. LPA issued a citation with a plan of correction (POC) (see LIC 809D). Facility had the required paperwork in all client files reviewed. LPA advised Administrator, who agreed, to ensure all required forms are signed by the responsible party. Administrator informed LPA that she, the facility Nurse, or the nurse consultant coordinate medical and dental visits for the clients and they take them to their appointments.

At approximately 11:50 AM, LPA reviewed medications and medication records which are maintained in compliance with regulation. LPA reviewed P&I monies and logs, which were organized and maintained according to regulation. However, LPA observed the surety bond amount was not correct. LPA discussed with Administrator that an updated Surety bond amount will need to be secured in order to comply with regulation.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:



Evidence of Surety Bond in the proper amount
LIC500- Personnel Report
LIC610- Emergency Disaster Plan

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted with Administrator and Appeal rights were given. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2024 01:20 PM - It Cannot Be Edited


Created By: Julie Florio On 07/02/2024 at 12:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BELEN HAVEN I
FACILITY NUMBER: 486803702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 2 out of 4 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Administrator to submit health screenings signed by a physician for the two staff files which were missing these documents by the POC due date 7/31/2024.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Administrator to submit proof of negative TB results for the staff file which was missing this documentation by POC due date 7/31/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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