Facility Evaluation Report, 03/03/2022 — Belle House, San Rafael CA

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Belle Housel for the purpose of conducting a Case Management-Incident inspection. LPA Sarangi met with Care Giver, Anthony Theis, and was granted access into the facility. Care Giver #2 arrived at 11:05 AM. Manager, Andrea Jackson arrived at 12:15 PM.

Department learned via a Special Incident Report (SIR) that on 02/09/2022 Client #1 (C1) left the facility unassisted at 03:30 PM. C1 returned to the facility unharmed and with no assistance from staff. Clients physician's report dated for 07/13/2021 states that client is not allowed to leave facility unassisted. (see copies, LIC 809-D). Department also learned via a Special Incident Report (SIR) that on 02/24/2022 Client #1 (C1) left the facility unassisted at 08:30 AM. C1 returned to the facility unharmed and with no assistance from staff. Clients physician's report dated for 07/13/2021 states that client is not allowed to leave facility unassisted. (see copies, LIC 809-D). In addition, LPA toured the facility with Care Giver #2 and found that the facility was clean and at a comfortable temperature with exits free from obstruction. LPA observed sufficient perishable and non perishable foods. Hot water temperature measured at Title 22 acceptable regulation of 105 to 120 degrees F in client’s bathroom while touring facility. However, LPA was unable to access Client #2's room due to the room being locked and the only way to access that room is through a key that is with Client #2. LPA was also unable to access the office due to Care Giver #2 having no key to either rooms. Staff members will obtain keys for both rooms in case of an emergency.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided to Care Giver #2.