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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803703
Report Date: 07/27/2022
Date Signed: 07/27/2022 10:27:06 AM

Document Has Been Signed on 07/27/2022 10:27 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 IIFACILITY NUMBER:
486803703
ADMINISTRATOR:LIVICA, BESSAFACILITY TYPE:
734
ADDRESS:3044 GERMAN STREETTELEPHONE:
(650) 580-3896
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 5CENSUS: 5DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Registered Nurse, Carlo Vera
Administrator, Bessa Livica		TIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Belen Haven II for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Registered Nurse, Carlo Vera and was granted access into the facility. Administrator, Bessa Livica arrived 25 minutes later.

LPA and Registered Nurse toured the facility and observed that the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on February 2022 at the time of the inspection. First Aid kit was inspected and found to be appropriate during the inspection. All smoke detectors and carbon monoxide detectors were tested on April 2022 by an outside company that provides a certificate. The certificate revealed that all smoke and carbon monoxide detectors were operational. Water temperature in clients bathrooms measured at 110 degrees, within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Medications were centrally stored and locked. Cleaning products and other toxins are located under the kitchen sink and in the laundry room that was locked and inaccessible to clients in care. There was a supply of cleaners, hygiene products and paper products available for clients. All bathrooms designated for clients were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the garage and around the facility. Staff have had all PPE training required and have been N95 Fit tested in March 2021. Next testing date for N95 Fit testing will be scheduled.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2022
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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Fire alarm and Life Safety systems inspection report
Register of residents

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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