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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 10:36:14 AM

Document Has Been Signed on 07/27/2022 10:36 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Registered Nurse, Carlo Vera
Administrator, Bessa Livica		TIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Belen Haven II for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO) on July 26, 2022. 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.

CCL received an incident report reporting a medication error. The error occurred on July 3, 2022 while outside agency nurse was dispensing medication. C1 was given the wrong medication during medication passing on July 3, 2022 (See LIC 809D). Responsible party and prescribing doctor were notified of medication error. LPA obtained copies of the in-house incident report indicating a medication error along with the Medication Assessment Record (MAR) for the month of July 2022 for C1 that reflects the said medication error. In addition, LPA observed the date of occurrence was on July 3, 2022 which falls outside the Reporting Requirements (See LIC 9102).

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were emailed to the 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
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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Document Has Been Signed on 07/27/2022 10:36 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 07/27/2022 at 09:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BELEN HAVEN II
FACILITY NUMBER: 486803703

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
80075(b)(5)(B)

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80075(b)(5)(B)-Health Related Services:
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff
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Licensee shall retrain ALL staff regarding medication passes as part of the Plan of Correction. In addition, Licensee shall provide LPA a written summary on how future compliance will be met.
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designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met:
(B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:

Based off an incident report that was forwarded to the Regional Office (RO) on July 26, 2022, C1 was administered the wrong medication during medication passes which poses an immediate Health, Safety and Personal Rights risk to the client(s) in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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