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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601028
Report Date: 07/07/2025
Date Signed: 07/07/2025 06:43:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2025 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20250703095027
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: 5DATE:
07/07/2025
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Caregivers Liwayway Noche and Arnel BulaonTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Staff did not provide proper hygiene care to resident
INVESTIGATION FINDINGS:
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On 7/07/2025, at 4:15 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to investigate the allegation above. Upon arrival, the LPA informed Caregivers Liwayway Noche and Arnel Bulaon of the purpose for this visit.

The complaint alleges staff did not provide proper hygiene care to Resident R1.
The LPA interviewed Witness W1 by phone. At the facility, the LPA interviewed Caregivers Noche and Bulaon, who described their hygiene care of R1. They also described the behaviors of R1 that have injured his skin during the day and at night that resulted in this complaint from the hospital staff. As the Home Health Nurse for R1, Witness W2 confirmed the Caregivers' statements, both in terms of the high level of care provided to R1 and R1's behaviors that injures his skin. The data collected and analyzed by the LPA shows that the staff were providing proper hygiene care to Resident R1, which does not confirm the allegation.

Continued on LIC 9099-C . . .
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20250703095027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BELROSE CARE HOME II
FACILITY NUMBER: 075601028
VISIT DATE: 07/07/2025
NARRATIVE
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. . . Continued from LIC 9099

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2