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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400072
Report Date: 07/12/2022
Date Signed: 07/12/2022 02:20:38 PM

Document Has Been Signed on 07/12/2022 02:20 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: 5DATE:
07/12/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Karae Hughes, Interim Program Director TIME COMPLETED:
02:30 PM
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On 7/12/2022 at 01:25 PM Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual Infection Control Inspection continued from 06/23/22. LPA met with Karae Hughes, Interim Program Director (PD). Facility has census of 5.

Facility has a COVID-19 mitigation plan on file. LPA requested a resident roster and staff roster be sent to CCLD. LPA and PD toured the facility inside and out including but not limited to common areas, activity room, workout room, TV room, bathrooms, kitchen, office and patio. No bodies of water were present, LPA observed screening stations at the entries that contained a thermometer, hand sanitizer, masks, face shields, gowns, and gloves. PD to add COVID-19 signage, post 20 seconds to hand washing signs in the kitchen and bath areas, and create an isolation cart for infection control. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and covered garbage cans; add paper towel holder and remove kitchen towels after each use. There was a surplus of PPE centrally located inside the facility that is accessible to all care staff. Hot water temperature in the measured at 116.8 degrees Fahrenheit (F) and the facility's temperature was 70 degrees (F). Fire extinguisher was observed full and last inspected on 04/06/2022. Smoke/Carbon Monoxide detectors observed operational and alerts fire department, and first aid kits complete. Cleaning supplies and solutions are are centrally stored in a locked area that are inaccessible to clients.

-LIC610 Emergency Disaster Plan (Reviewed)

Exit interview conducted and a copy of this report provided to Karae Hughes, Interim Program Director (PD).
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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