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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803703
Report Date: 08/04/2023
Date Signed: 08/04/2023 04:26:11 PM

Document Has Been Signed on 08/04/2023 04:26 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
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: 4DATE:
08/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Carlo Vera & Sheila Rafols, Lead Staff/RNTIME COMPLETED:
04:40 PM
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On 8/4/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Lead Staff/Registered Nurse (RN), Carlo Vera and Sheila Rafols. The facility currently provides care for 4 clients, all of which were present at the time of visit.

LPA continued with a tour of the facility with RN; facility was found to be clean and at a comfortable temperature. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 7/21/2023. Smoke and carbon monoxide detectors were inspected by an outside agency as of April 2022. LPA requested for Administrator to contact the inspection agency and determine whether a new inspection is required. Technical Advisory. There was a sufficient amount of food supply meeting client special provisions based on dietary needs. There was an ample supply of linens, hygiene and medical products available for clients located in the garage. All client’s bedrooms have proper lighting. LPA toured the backyard and found one emergency exit to be free from obstructions.

Water was tested at faucets accessible to clients and measured 105.2 degrees F which falls within Title 22 regulation. Sharps, cleaning supplies and other items that could pose harm if accessible to client in care were found to be secured in the kitchen areas and are inaccessible to clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats. Medications are located in a designated medication room secured in locked cabinets and medication carts. Spot check of medication administration and centrally stored medication records were found to be in order. In addition, LPA conducted a file review for all clients and found all medical and care plan documentation up to date.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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: 08/04/2023
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Administrator, Bessa Livica's Administrator Certification 6040564735 is currently active until 7/20/2024.

LPA requested the following documents be sent to CCL by COB 9/4/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Surety Bond
Control of Property
Fire Alarm & Life Safety Systems Certification (Updated if determined to be needed)

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC809 (FAS) - (06/04)
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