486803703-8-10-2026-21-AS-MCUA-DWTT24-20260810142006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803703
Report Date: 08/10/2026
Date Signed: 08/10/2026 02:20:20 PM

Document Has Been Signed on 08/10/2026 02:20 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 II		FACILITY NUMBER:	486803703
ADMINISTRATOR/ DIRECTOR:	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:	08/10/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:37 PM
MET WITH:	Aida Felix (House Manager)		TIME VISIT/ INSPECTION COMPLETED:	02:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Inspection for this facility and met with Administrator, Bessa Livica. All clients were attending to day program. Annual fees are current. Required postings observed. LPA/staff toured the facility and it was found to be clean, passageways free from obstructions 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 July 2026. Smoke and carbon monoxide detectors were inspected by an outside agency on June 15, 2026. There was adequate supply of linens, hygiene and medical products. All client’s bedrooms have proper lighting and equipment appropriate for client care needs. Water was tested at faucets accessible to clients and measured 106.1 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. The facility has generators, home is fire sprinkled, it has interior fire door and last emergency disaster drill was conducted on 7/6/26. Emergency food and water for at least 72-hours. Facility has at least two days of perishable and one week of non-perishable foods. Currently there are clients who are fed through G-tubes. LPA was able to verify that facility maintains a 7+ day supply of client prescribed nutritional formulas and supplies. LVNs and RNs are responsible for all tube feeds and medications. Facility van contain a fire extinguisher and first aid kit. Continued onto LIC809-C

Bethany Moellers
Marisol Cuadra
	DATE: 08/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026

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: 08/10/2026

NARRATIVE

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Continued from LIC809...

File review was initiated at 1:00 pm. Three staff files and five client files were reviewed. Staff have required First Aid and CPR certificates. Training hours were complete. All clients have medical assessments and care plans updated. Administrator, Bessa Livica's Administrator Certification 7012086735 is currently active until 7/20/2028. Full bed rails and PRN waivers on file. Client's exceptions were reviewed and no exceptions are needed at this time. 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. Cash resources reviewed.

Administrator agrees to submit updates of the following by 8/31/2026:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
Surety Bond

No deficiencies cited during today's visit. Exit interview conducted with administrator and copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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