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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803703
Report Date: 07/26/2024
Date Signed: 07/26/2024 03:32:07 PM

Document Has Been Signed on 07/26/2024 03:32 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/
DIRECTOR:
LIVICA, BESSAFACILITY TYPE:
734
ADDRESS:3044 GERMAN STREETTELEPHONE:
(650) 580-3896
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 5CENSUS: 4DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:02 PM
MET WITH:Carlo Vera, Lead Staff/RN & Besa Livica, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 7/26/2024, 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. Administrator, Besa Livica was contacted and arrived later in the visit. The facility currently provides care for 4 clients, some of which were attending program and but arrived later in the visit.

LPA continued with a tour of the facility with staff; 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 5/9/2024. Smoke and carbon monoxide detectors were inspected by an outside agency on June 17, 2024. 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. All client’s bedrooms have proper lighting and equipment appropriate for client care needs. LPA toured the backyard and found one emergency exit to be free from obstructions.

Water was tested at faucets accessible to clients and measured 105.5 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 area. Bathrooms were equipped with necessary equipment and devices to meet client needs. Medications are located in a designated medication room secured in locked cabinets and medication carts. Spot check of medication administration and narcotic records were found to be in order. LPA and Administrator discussed narcotic and medication destruction protocols. In addition, LPA conducted a file review for all clients and found all medical and care plan documentation up to date. Staff conduct frequent inspection on installed and portable generators for client requiring electronic health devices. Emergency disaster drills are also conducted on a monthly basis. LPA conducted P&I check for all clients and found ledger to be in order and not commingled.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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: 07/26/2024
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Administrator, Bessa Livica's Administrator Certification 7012086735 is currently pending for re-certification with valid date through 07/20/2026 once approved.

LPA requested the following documents be sent to CCL by COB 8/9/2024:

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

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

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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