486803703-12-14-2023-21-AS-VBEI-CYMTT2-20231218140001

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803703
Report Date: 12/14/2023
Date Signed: 12/14/2023 10:14:12 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20230913150659

FACILITY NAME:	BELEN HAVEN II		FACILITY NUMBER:	486803703
ADMINISTRATOR:	LIVICA, BESSA		FACILITY TYPE:	734
ADDRESS:	3044 GERMAN STREET		TELEPHONE:	(650) 580-3896
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	5	CENSUS: 5	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Carlo Vera, RN/Lead Staff		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Neglect/Lack of Care & Supervision resulting in client contracting HPV

INVESTIGATION FINDINGS:

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On 12/14/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and a was greeted by RN/Lead Staff, Carlo Vera. During the course of the investigation, the facility was toured, staff, clients and outside parties were interviewed, client and facility records were reviewed, and observations made. Investigation was conducted and completed by Community Care Licensing Investigations Branch (IB) investigator and the following was reported.

On 8/24/2023, Client (C1) underwent an exam and was found to test positive for Human Papillomavirus (HPV). A previous exam completed on 9/23/2019, C1 had negative results for HPV, but medical records indicated that the sample was “endocervical/transformation zone component absent or insufficient”.
Interviews with staff reported that there were no concerns regarding C1 or inappropriate behavior involving current or former facility staff. Interviews with staff and outside parties reported that clients at the facility require two person assist and clients are never alone with one facility staff at a time when they are being changed or bathed. There are always two to four facility staff on each shift. Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230913150659

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 II	FACILITY NUMBER: 486803703
	VISIT DATE: 12/14/2023

NARRATIVE

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In addition, outside medical professional (I1) indicated that C1 could have contracted HPV “when C1 was 10 years old,” or have had it “forever,” but tested negative for HPV due to the possibility that patients can receive a negative result but be a carrier of HPV. I1 stated that the outcome of a negative versus positive test result for HPV can be a result of the patients’ immune system at the time the test sample is taken. I1 further stated that it is possible that the next time C1 is tested the result is likely to be negative.
Due to a lack of corroborating evidence to determine how C1 contracted HPV, the allegation is found to be unsubstantiated. Allegation, neglect/lack of care & supervision resulting in client contracting a sexually transmitted disease is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies cited during today's visit.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

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