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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011400072
Report Date: 11/01/2021
Date Signed: 11/01/2021 04:10:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/26/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20211026093511
FACILITY NAME:BONITA HOUSE, INCFACILITY NUMBER:
011400072
ADMINISTRATOR:RICK CRISPINOFACILITY TYPE:
772
ADDRESS:1410 BONITA AVENUETELEPHONE:
(510) 526-4765
CITY:BERKELEYSTATE: CAZIP CODE:
94709
CAPACITY:15CENSUS: 7DATE:
11/01/2021
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Karae HughesTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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On 11/1/2021 Licensing Program Analysts (LPA) L.Ibo and L. Holmes arrived at the facility unannounced to investigate the above allegation. LPAs called Administrator Ryan Shallant, Administrator is not available during the visit, Administrator gave permission to LPAs to provide copy of the report to staff Karae Hughes (admissions manager). LPAs informed the purpose of the visit to Administrator and Staff Karae.

LPAs conducted interview, Administrator admitted that facility had bed bugs on of the resident’s room (room #2), the incident happened on 10/25/2021. Facility hired professional exterminator (terminix)on 10/26/2021 to eliminate beg bugs, facility also hired professional cleaner (Stanley Steamer) to clean room #2 and facility disposed mattress and box and purchase a new one. As of now per staff Karae H. the room is empty. Staff are also trained on how to prevent bed bugs at the facility.

...Continue LIC9099C...




Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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 3
Control Number 15-AS-20211026093511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BONITA HOUSE, INC
FACILITY NUMBER: 011400072
VISIT DATE: 11/01/2021
NARRATIVE
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A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency was cleared today.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates along with the LIC9098 Proof of Correction and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Staff Karae H.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20211026093511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BONITA HOUSE, INC
FACILITY NUMBER: 011400072
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2021
Section Cited
CCR
81087(a)(1)
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81087 BUILDINGS AND GROUNDS (a) The facility shall be clean, safe, sanitary and in good repair...(1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidence by:
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Deficiency is corrected as of 11/1/2021.
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Based on interviews licensee did not comply with section above, facility had bed bugs on 10/26/2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
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Facility hired exterminator to irradiate bed bugs from room #2.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3