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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601320
Report Date: 08/22/2022
Date Signed: 08/22/2022 03:16:39 PM

Document Has Been Signed on 08/22/2022 03:16 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, 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: 6DATE:
08/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rosa Junsay, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 8/22/2022 at 2:30PM, Licensing Program Analysts (LPAs) G. Luk and J. Sampair arrived unannounced to conduct a case management visit. LPAs met with Administrator, Rosa Junsay.

While LPAs was conducting a complaint investigation to deliver findings, the following deficiency was observed.

During complaint investigation, it was observed that facility did not have pre-placement appraisal or care plan for R1.


The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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 2
Document Has Been Signed on 08/22/2022 03:16 PM - It Cannot Be Edited


Created By: Grace Luk On 08/22/2022 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELROSE CARE HOME III
FACILITY NUMBER: 075601320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited
CCR
87457(c)

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Pre-Admission Appraisal - General. Prior to admission...an appraisal of his/her individual service needs in comparison with the admission criteria... This requirement is not met as evidence by:
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Administrator has agreed to review regulations regarding to admission of a new resident. Administrator will submit a written statement acknowledging that all current and future residents will have a pre-placement appraisal to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by not obtaining pre-placement appraisal which poses a potential health and safety risk to the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022


LIC809 (FAS) - (06/04)
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