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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400072
Report Date: 06/28/2024
Date Signed: 06/28/2024 01:16:33 PM

Document Has Been Signed on 06/28/2024 01:16 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/
DIRECTOR:
RICK CRISPINOFACILITY TYPE:
772
ADDRESS:1410 BONITA AVENUETELEPHONE:
(510) 526-4765
CITY:BERKELEYSTATE: CAZIP CODE:
94709
CAPACITY: 16CENSUS: 3DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Melissa Bergson, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On 06/28/2024 around 10:10 AM Licensing Program Analyst (LPA) L. Holmes arrived announced to conduct a required annual required inspection. LPA met with Melissa Bergson, Program Director (PD). Facility has recently reopened and is under construction.

LPA toured the facility inside and out including but not limited to common areas, resident rooms on the first floor, bathroom, kitchen and office. No bodies of water were present. Facility has sufficient supplies of PPE per PD. Medications are centrally stored in a locked area that is inaccessible to clients. First Aid kit complete.

Facility has a 2-day supply of perishable foods and 7-days of non-perishable foods. Hand washing poster observed in the bathroom and the water temperature was a comfortable degree while under construction during visit. Smoke and carbon monoxide detectors are combined and observed throughout the facility. No accessible bodies of water were observed. Fire extinguisher last inspected 06/25/2024. Indoor and outdoor passageways were free of obstruction.

-Standard Certificate for Administrator
-Review regulation to update records for current Administrator
-Create Emergency Contact Binder
-Update Client files with LIC602

No deficiencies are cited on this date.

Exit interview conducted. A copy of this report provided to Kim Sonico-Lewis, Director of Human Resources
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
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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