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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803702
Report Date: 06/27/2025
Date Signed: 06/27/2025 02:15:31 PM

Document Has Been Signed on 06/27/2025 02:15 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: 5DATE:
06/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Administrator-Bessa LivicaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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At approximately 10:40 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was met by DSP caregiver Josephina Calderon, who called Administrator Bessa Livica. Administrator Bessa arrived to the facility at approximately 11:05 AM. Facility is an Adult Residential Facility For Persons with Special Health Care Needs (ARFPSHN) with five (5) non-ambulatory clients in care. LPA was informed that four (4) of five (5) clients were present and one (1) client was in day program. Facility cares for two (2) clients with stage three (3) and/or stage four (4) pressure wounds that do not require exceptions from Community Care Licensing (CCL) due to their ARFPSHN license in California.

Both Ring doorbell and default doorbell were observed to be out of order and a technical advisory was issued to ensure a working doorbell was made available for visitors.

At approximately 11:20 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, 3 client 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 goods for each of the clients.

Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 06/27/2025
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Continued from LIC809...

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 extinguishers was observed fully charged and were last inspected March 2024 and are to be inspected next month, July 2025. 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 2025. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kit. Facility has a two backup generators.

At approximately 11:00 AM, LPA reviewed five (5) staff files and five (5) client files. 5 of 5 staff and 5 of 5 client files reviewed had the required documentation including TB clearance.

Facility had the required paperwork in all client files reviewed. 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. In addition, an MD visits the home every 60 days.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
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: 06/27/2025
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At approximately 1:30 PM LPA reviewed P&I monies and logs, which were organized and maintained according to regulation. However, LPA observed the home had more money then their current bonding. Licensee left a message with their insurance agent to increase their surety bonding and licensee submitted an increased Affidavit Regarding Client Cash Resources (LIC400) during my visit and will submit proof of increased bonding are required by the new LIC400 obtained during this visit. (Technical Violation issued)

Updated copies of the following documents were obtained during my inspection including:
LIC400 Affidavit
LIC500- Personnel Report
LIC 308 Designation of Facility Responsibility
LIC610D- Emergency Disaster Plan
LIC9020 - Registrer of Facility Clients

Licensee to submit to CCL:
Updated evidence of increased Surety bonding to match the newest LIC400 Affidavit received today.

No deficiencies are cited today.

Exit interview conducted with Administrator and Appeal rights were given. Signature on form confirms receipt.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
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