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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440756
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:26:21 PM

Document Has Been Signed on 09/22/2022 01:26 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BOBBI FRENCH RESIDENTIAL CARE FACILITYFACILITY NUMBER:
011440756
ADMINISTRATOR:FRENCH, BOBBI L.FACILITY TYPE:
735
ADDRESS:521 - 32ND STREETTELEPHONE:
(510) 428-9424
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 6CENSUS: 4DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Bobbi French, AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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On 9/22/2022 starting at 10:15 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator and disclosed the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, and kitchen. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Mitigation Plan on file.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· At 10:20 a.m., LPA observed facility was not cleaned daily, many stains was observed on the toilet and table clothes.
· At 10:40 a.m., during record review, LPA observed Administrator did not keep clients' Centrally Medication Records on file.
· At 10:50 a.m., during record review, LPA observed facility does not have an Emergency Disaster Plan (LIC 610)
· At 11:00 a.m., during record review, Administrator admitted that no booster was received.
· At 11:10 a.m., during interview, LPA observed Administrator didn't have knowledge of keep update information from CCLD. Administrator admitted that she didn't have access to emails and she will designate her daughter to assist her.
· At 11:40 a.m., during interview, LPA observed Administrator didn't have active Administrator Certificate.

Continue on LIC809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BOBBI FRENCH RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 011440756
VISIT DATE: 09/22/2022
NARRATIVE
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The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 09/22/2022 01:26 PM - It Cannot Be Edited


Created By: Catherine Lin On 09/22/2022 at 12:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BOBBI FRENCH RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 011440756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above, many stains in toilet and table clothes which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Administrator agrees to clean facility daily, and submit self-certification to CCL by the POC due date.
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, No active Administrator Certificate was observed which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2022
Plan of Correction
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Administrator agrees to start the process of renewing the certificate, and submit proof of document to CCL by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 09/22/2022 01:26 PM - It Cannot Be Edited


Created By: Catherine Lin On 09/22/2022 at 12:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BOBBI FRENCH RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 011440756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80064(a)(3)
Administrator Qualifications and Duties
(3) Knowledge of and ability to comply with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, Administrator was lack of knowledge of updating regulations which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Administrator agrees to designate another staff member to keep updating information, and submit LIC308 to CCL by the POC due date. .
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 4 out of 4 did not have records of centrally stored medication on file which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Administrator agreed to keep centrally stored medication record on file moving forward, and submit self-certification to CCL by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 09/22/2022 01:26 PM - It Cannot Be Edited


Created By: Catherine Lin On 09/22/2022 at 12:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BOBBI FRENCH RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 011440756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, no emergency and disaster plan was observed in facility which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Administrator agrees to have an updated emergency disaster plan LIC610, post in faciltiy, and submit a copy to CCL by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
Page: 5 of 13