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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601320
Report Date: 03/04/2024
Date Signed: 03/04/2024 03:44:44 PM


Document Has Been Signed on 03/04/2024 03:44 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 IIIFACILITY NUMBER:
075601320
ADMINISTRATOR:JUNSAY, ROSAFACILITY TYPE:
740
ADDRESS:226 NORMANDY LANETELEPHONE:
(925) 689-8831
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee Rosa JunsayTIME COMPLETED:
04:15 PM
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On 3/4/2024 at 10:30 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 Evangeline Polito and Justo Garcia. Licensee Rosa Junsay arrived at approximately 11:15 AM.

LPA toured the interior and exterior of the facility. LPA inspected the kitchen, dining area, restrooms, community living spaces, bathrooms, resident rooms, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the living room was measured at 68.7 degrees Fahrenheit at 11:57 AM. Fire extinguisher was fully charged and last serviced on 12/6/2023. Carbon monoxide and smoke detectors were fully operational. The LPA observed postings in the facility that included a complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council, and Rights to Family Council.

An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. The LPA reviewed facility records, records of 5 staff members, and records of 5 residents. The LPA interviewed 2 staff members and 2 residents.

No citations issued during inspection.

Exit interview conducted with Licensee. A copy of this report provided to the Licensee via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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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