486803702-7-15-2026-21-AS-SSTN-DVZSZT-20260715141941

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803702
Report Date: 07/15/2026
Date Signed: 07/15/2026 02:20:10 PM

Document Has Been Signed on 07/15/2026 02:20 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 I		FACILITY NUMBER:	486803702
ADMINISTRATOR/ DIRECTOR:	LIVICA, BESSA		FACILITY TYPE:	734
ADDRESS:	3840 STAFFORD SPRINGS WAY		TELEPHONE:	(650) 580-3896
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 5		CENSUS: 5	DATE:	07/15/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Administrator Bessa Livica		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 12:00 PM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was met by Administrator Bessa Livica. 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 away at day programming and one (1) client was present during today's inspection. Facility cares for two (2) clients with a history 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 working this year. At approximately 12:15 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, without odors 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. Bedrooms are noted to have heavy duty overhead lifts, as well as, wall televisions and projection television that can be projected onto the ceilings for client convenience and allow a client to lay flat if needed to reduce the risk of pressure wounds. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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)

Page: 2 of 4

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: 07/15/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809...

Facility, currently, four (4) 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.

There are two covered patio and seating areas in the backyard with outdoor space for activities. LPA observed an activity schedule, games, large television and seating area for clients, as well as a facility computer available for client use. Facility has internet available to clients in care and the phone was tested and found operational.

Facility's fire extinguishers (2) was observed fully charged and were last inspected June 2026. Smoke and Carbon Monoxide detectors were tested and found to be operational during inspection.

Facility conducts regular monthly emergency/disaster drills, and the most recent drill was conducted July 2026. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kit. Facility has a large hardwired gas generator to run sensitive medical equipment, as well as a large portable gas generator for same.

At approximately 12:45 PM, 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.

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.

At approximately 1:30 PM LPA observed P&I monies and logs, which were organized and maintained according to regulation.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 07/15/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809-C

At approximately 1:45 PM LPA performed a spot check of the Medicine Administrator Record (MAR) and observed the medicine administration record to be accurate.

Updated copies of the following documents were obtained during my inspection including:
LIC500- Personnel Report
LIC9020 - Register of Facility Clients
Most recent hard-wired "Wet Pipe" fire suppression system inspection
Updated nine (9) page LIC610D- Emergency Disaster Plan

No deficiencies are cited today.

Exit interview conducted with Administrator whose signature on form confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC809 (FAS) - (06/04)

Page: 4 of 4