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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440756
Report Date: 11/13/2024
Date Signed: 11/13/2024 04:28:52 PM

Document Has Been Signed on 11/13/2024 04:28 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:BOBBI FRENCH RESIDENTIAL CARE FACILITYFACILITY NUMBER:
011440756
ADMINISTRATOR/
DIRECTOR:		GOOLSBY, NORMANFACILITY TYPE:
735
ADDRESS:521 - 32ND STREETTELEPHONE:
(510) 428-9424
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 6CENSUS: 1DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Bobbi French LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 11/13/2024 at 12:30 PM, Licensing Program Analysts (LPAs) D. Doidge and L. Holmes arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Licensee Bobbi French and explained the purpose of the visit.

LPAs toured the facility including but not limited to, bedroom, bathroom, kitchen, common area and yard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 69 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 115.1 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed with no indication of service date noted. Emergency Disaster Plan was not posted. No drills have been conducted. First aid kit was observed to be complete. LPAs could not review residents nor staff records as there were none in the facility

The following deficiencies were observed:
At 12:38 PM, LPAs inspected the kitchen found knives, a hammer, an axe, lighters and scissors unlocked in multiple drawers and on counter top.

At 12:40 PM, LPAs observed medications and cleaning solutions in multiple cabinets also in kitchen.

Continued on 809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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 4
Document Has Been Signed on 11/13/2024 04:28 PM - It Cannot Be Edited


Created By: Lisha Holmes On 11/13/2024 at 03:34 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as fence leading to backyard obstructed with clutter blocking paths, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Licensee to clean up backyard and ensure gate can open freely. Licensee to provide proof by way of photos to LPA by POC date
Type A
Section Cited
HSC
1507(c)(1)(A)
General Provisions
(1) For regional center clients the following shall apply: (A) An individualized health care plan, which may be part of a client's individual program plan, shall be prepared for each client by a health care team that shall include the client or his or her designee if the client is not able to participate in planning his or her health care, the client's primary care physician or nurse practitioner or other health care professional designated by the physician or nurse practitioner, the licensee or licensee's designee, any involved social worker or regional center worker, and any health care professional designated to monitor the client's individualized health care plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as resident did not have a physicians report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Licensee to provide physicians report for resident to LPA by POC 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/13/2024 04:28 PM - It Cannot Be Edited


Created By: Lisha Holmes On 11/13/2024 at 03:34 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(1)(A)1
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must receive training from a licensed professional. 1. The licensee shall obtain written documentation from the licensed professional outlining the procedures and the names of facility staff who have been trained in those procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as there are no staff records of training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee to provide training records for all staff showing staff that adminiter medication are fully trained.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BOBBI FRENCH RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 011440756
VISIT DATE: 11/13/2024
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Continued from 809

At 1:00 PM LPAs inspected laundry room, laundry detergent and other cleaning supplies were found unlocked.

At 1:10, LPAs observed refrigerator in laundry room with unlabeled bags of food and flour. Bins in refrigerator were unclean.

At 1:40 PM, LPAs inspected 3 bedrooms. Closet doors were off track and not sliding.

At 2:00 PM, LPAs observed bars on windows.

At 2:10 PM, LPAs Observed fence leading to backyard obstructed with miscellaneous items covered by a blue and brown tarp which blocked path.

The above deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22 and/or Health Safety Code failure to correct deficiencies by POC dates may result in additional civil penalties.

The following reports are requested to be sent to LPA by 11/20/2024: LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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