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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600619
Report Date: 01/22/2025
Date Signed: 01/22/2025 02:48:37 PM

Document Has Been Signed on 01/22/2025 02:48 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:RUSSELL STREET RESIDENCEFACILITY NUMBER:
015600619
ADMINISTRATOR/
DIRECTOR:		VERNETTE SUGGSFACILITY TYPE:
735
ADDRESS:1741 RUSSELL STREETTELEPHONE:
(510) 843-3420
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY: 18CENSUS: 17DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Vernette Suggs, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 01/22/25 at 10:10 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual inspection, and explained the purpose of the visit with Administrator (ADM), Vernette Suggs.

LPA observed one (1) staff preparing lunch, and a client sitting outside. The facility has a COVID-19 mitigation plan in place and on file. LPA observed COVID-19 signage at the front entrance, hand sanitizer, masks, and visitor log. LPA requested a resident and staff roster, discussed staffing schedules, training, 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. Clients have individual rooms/apartments. Pathways were observed to be free of obstruction and fire hazards. First Aid kit observed complete. LPA observed the facility room temperature at 68 degrees Fahrenheit. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. PPEs and paper supplies are adequate. Fire extinguisher appeared full and was last serviced on 06/18/2024. Smoke/carbon detectors are combined and observed operational. Sands bags, flashlights, interior exit lighting and signs are installed and available.

Five (5) resident files and four (4) staff files reviewed.

The following forms are to be updated and submitted to CCLD:01/29/2025.
-Resident Roster (Reviewed)
-LIC500 Personnel Report/Roster (Reviewed)
-LIC308 Designation of Administrative Responsibility (To be updated)
-LIC610 Emergency Disaster Plan (Reviewed and to be updated)
-An updated copy of Administrator Certificate(s) (Reviewed)

Exit interview and a copy of this report provided Administrator, Vernette Suggs.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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