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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601028
Report Date: 01/31/2024
Date Signed: 01/31/2024 12:56:36 PM


Document Has Been Signed on 01/31/2024 12:56 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: 4DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Rosa JunsayTIME COMPLETED:
01:30 PM
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On 1/31/2024 at 10:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Caregivers Liwayway Noche and Rossett Daniel. Licensee Rosa Junsay arrived at approximately 11:15 AM.

The LPA inspected the facility inside and outside. All outdoor and indoor passageways were free of obstruction. Outside, there were no bodies of water. Inside, the temperature was measured at 74.7 degrees Fahrenheit. The LPA observed adequate lighting in all of the rooms for the comfort and safety of the residents. LPA observed 7 days of nonperishable and 2 days of perishable foods on hand. Sharps were stored inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition. Fire extinguisher was observed to be fully charged and last serviced on 12/6/2023.

The LPA reviewed the records of 4 residents and 5 staff members. The LPA interviewed 2 residents and 2 staff members.

Required Annual Inspection complete and no citations issued during the visit.

Exit interview conducted with Licensee. A copy of this report provided via email to the Licensee.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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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