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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601320
Report Date: 04/12/2023
Date Signed: 04/12/2023 12:23:20 PM

Document Has Been Signed on 04/12/2023 12:23 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:
04/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee Rosa JunsayTIME COMPLETED:
12:45 PM
NARRATIVE
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On 04/12/2023, during an unannounced complaint inspection, Licensing Program Analyst (LPA) J. Sampair observed a bed railing on resident R1's bed without a physician's order and Caregiver Evangeline Polito who was not associated with the facility for which a civil penalty was issued.

Deficiencies cited per Title 22 California Code of Regulations is listed on the LIC9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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 04/12/2023 12:23 PM - It Cannot Be Edited


Created By: James Sampair On 04/12/2023 at 11:29 AM
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: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2023
Section Cited
CCR
87608(a)(3)

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87608 POSTURAL SUPPORTS (a) ... Postural supports may be used under the following conditions ... (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record.

This requirement was not met as evidenced by:
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Bed raining was removed from resident R1's bed during the visit.
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Based on observation and record review, the licensee did not have a physician's order for a bed railing for R1, which posed a potential health, safety or personal rights risk to persons in care.
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Type A
04/13/2023
Section Cited
CCR87411(g)(1)

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance

This requirement was not met as evidenced by:
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Transfer association to facility on or before due date.
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Based on observation and record review, the licensee did not have a physician's order for a bed railing for R1, which posed a potential health, safety or personal rights risk to 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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023


LIC809 (FAS) - (06/04)
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