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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400072
Report Date: 06/23/2022
Date Signed: 06/23/2022 04:18:09 PM

Document Has Been Signed on 06/23/2022 04:18 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:BONITA HOUSE, INCFACILITY NUMBER:
011400072
ADMINISTRATOR:RICK CRISPINOFACILITY TYPE:
772
ADDRESS:1410 BONITA AVENUETELEPHONE:
(510) 526-4765
CITY:BERKELEYSTATE: CAZIP CODE:
94709
CAPACITY: 15CENSUS: DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:CaregiverTIME COMPLETED:
03:40 PM
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On 06/23/2022 at 03:20 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control inspection. LPA was greeted by one staff prior to entry and LPA explained the purpose of the visit. The caregiver stated that the facility was having a staff meeting and was advised on 06/22/2022 that the Interim Administrator/Manager has contracted COVID-19. LPA left business card and requested an incident report. LPA does not have full PPE and left the facility as an attempted visit.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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