<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601028
Report Date: 04/09/2024
Date Signed: 04/09/2024 01:57:47 PM


Document Has Been Signed on 04/09/2024 01:57 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BELROSE CARE HOME IIFACILITY NUMBER:
075601028
ADMINISTRATOR:JUNSAY, ROSA C.FACILITY TYPE:
740
ADDRESS:36 BAI GORRY PLACETELEPHONE:
(925) 932-8822
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
04/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Caregiver Arnel BulaonTIME COMPLETED:
02:00 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
On 4/9/2024 at 12:45 PM, Licensing Program Analyst (LPA) J. Sampair arrived at facility unannounced to conduct this case management visit. Upon arrival, the LPA stated the purpose of the visit to Caregivers Liwayway Noche and Arnel Bulaon, which was to verify the health and safety of their new residents who were admitted on 4/6/2024 due to the fire at Casa Blanca Homes (071441125).

At 12:50 PM, the LPA and Caregiver Bulaon met with Residents R1 and R2. The Caregiver stated that because of the water used by the fire department when putting out the fire, the belongings of R1 and R2 were wet when they arrived. They dried all of those belongings. The LPA observed that both R1 and R2 were safe and healthy.

No citations issued during this visit.

Exit interview conducted with Caregiver Bulaon. A copy of this report provided via email to the Licensee.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1