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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700946
Report Date: 02/06/2025
Date Signed: 02/06/2025 02:40:36 PM

Document Has Been Signed on 02/06/2025 02:40 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BELHAVEN ESTATE IIFACILITY NUMBER:
342700946
ADMINISTRATOR/
DIRECTOR:
BROOKS, DANIELFACILITY TYPE:
740
ADDRESS:9046 ELM AVETELEPHONE:
(831) 801-4626
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 6DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Daniel and Monica BrooksTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 02/06/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced to conduct an annual inspection. LPA met with Administrator Daniel Brooks and Monica Brooks and explained the purpose of the visit.

LPA and staff conducted a tour of the facility. Areas toured include but not limited to resident bedrooms, bathrooms, kitchen, and common areas. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven(7) days and perishable foods for a minimum of two (2) days. Hot water was measured at 114.2 degrees at the kitchen sink. Toxins and cleaning supplies are locked and inaccessible to residents in care. LPA observed fire detectors and carbon monoxide alarms to be operable. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility.

LPA reviewed four (4) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. LPA reviewed four (4) staff files. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current training completed.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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