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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600619
Report Date: 04/22/2022
Date Signed: 04/25/2022 08:29:25 AM

Document Has Been Signed on 04/25/2022 08:29 AM - 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:RUSSELL STREET RESIDENCEFACILITY NUMBER:
015600619
ADMINISTRATOR:VERNETTE SUGGSFACILITY TYPE:
735
ADDRESS:1741 RUSSELL STREETTELEPHONE:
5108433420
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY: 18CENSUS: 17DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Staff, Robin Wimberly and ADM, Vernette Buggs TIME COMPLETED:
04:15 PM
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On 04/22/2022 at 02:20 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual infection control inspection and explained the purpose of the visit with Staff, Robin Wimberly (S1). S1 stated that she was the only staff person available. At 02:28 PM, LPA called the Administrator, Vernette Suggs (ADM). ADM explained that she is out of the office to support another staff member with a family medical issue and that S1 can sign the report. LPA observed two (2) clients sitting outside and (4) clients relaxing and watching television in the TV room.

The facility has a COVID-19 mitigation plan in place and on file. LPA observed a screening area located near the front entrance with no touch temperature probe, hand sanitizer, masks, and visitor log. LPA obtained a resident and staff roster, discussed staffing schedules and inspected the facility inside and outside.

LPA observed COVID-19 signs posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. First Aid kit observed complete. LPA observed hot water measure at 105.5 and facility room temperature at 72 degrees Fahrenheit. There was a sufficient supply of 7-day perishables and 2-day supply of non-perishable foods. PPE's and paper supply are adequate. Fire extinguisher appeared full and was last serviced on 04/19/2022. Smoke/carbon detectors are combined and observed operational. ADM arrived at 03:35 PM and discussed infection control with LPA..

Exit interview and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
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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