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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600265
Report Date: 05/24/2022
Date Signed: 05/24/2022 04:53:34 PM

Document Has Been Signed on 05/24/2022 04:53 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:WILLIAMS BOARD & CARE HOME IIFACILITY NUMBER:
075600265
ADMINISTRATOR:FREDERICK WILLIAMSFACILITY TYPE:
735
ADDRESS:4229 TAFT STREETTELEPHONE:
(510) 237-2411
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 6CENSUS: DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Ida Moore, Care StaffTIME COMPLETED:
05:05 PM
NARRATIVE
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On 05/24/2022 at 12:35 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPA was greeted by a client at the entry and explained the purpose of the visit. Ida Moore, Care Staff, introduced herself. Frederick Williams (ADM) was telephoned by Ida and was given permission to sign the report.

Facility has a COVID-19 mitigation plan on file. LPA requested a staff and resident roster. LPA observed hand sanitizer and COVID-19 signage in the common area. A thermometer, COVID-19 screening questionnaire, masks, gloves and a visitor sign-in log need to be present at the entry. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. LPA observed mask, cough etiquette, social distancing and handwashing signs posted in the common area. ADM to post 20 seconds to handwashing signs and add covered garbage cans to all shared bedrooms #1, #2 and #3. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. Handwashing stations need to be equipped with soap, paper towels and covered garbage cans for the downstairs and upstairs bathrooms. A 30-day supply of PPE should be centrally stored and accessible to all Care Staff. Hot water temperature in the shared residents' bathroom was measured at 110.9 degrees Fahrenheit (F) and the facility's temperature was 74 degrees (F). Fire extinguisher was observed full and last inspected on 02/24/2022. Smoke/Carbon Monoxide detectors were observed operational and first aid kit was not available.

The following forms are to be updated and submitted to CCLD: 05/31/2022
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610 Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)

...continued on 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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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: WILLIAMS BOARD & CARE HOME II
FACILITY NUMBER: 075600265
VISIT DATE: 05/24/2022
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The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

LPA observed the following during course of inspection:
· Approximately at 1:05 PM, LPA observed white vanity with the cabinet door hanging from the hinges in the downstairs bathroom.
· Approximately at 1:05 PM, LPA observed an off-white siding panel, a ladder, and rake along the backyard side fence.
· Approximately at 1:15 PM, LPA observed dust and what appeared to be mold or mildew on the outside areas of the tub and the perimeter of the toilet and bathroom floor area.
· Approximately at 1:10 PM, LPA observed what appeared to be mold or mildew surrounding the entire window in bedroom #2.
· Approximately at 1:20 PM, Care Staff said there was not a complete first aid kit.
· Approximately at 1:25 PM, LPA observed the kitchen floor with what appeared to be grease stains and mouse traps were present on top of the stains. The stove top has food and/or grease residue. The stove top vent has dust and grease stains, the refrigerator has grease stains on the outside and the inside has liquid and/or food spillage.
· Approximately at 1:35 PM, LPA observed that the dining area that leads to the kitchen also needs the floor to be cleaned from spots, food particles and dust which is connected to the carpeting that leads to the living area and throughout the entire facility.

Exit interview conducted. Copy of report and appeal rights provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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Document Has Been Signed on 05/24/2022 04:53 PM - It Cannot Be Edited


Created By: Lisha Holmes On 05/24/2022 at 03:45 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: WILLIAMS BOARD & CARE HOME II
FACILITY NUMBER: 075600265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings 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, the licensee did not comply with the section cited above. LPA observed mold and/or mildew in the window of bedroom #2. Bedroom #1 does not have window coverings over the entire window. Debris, a ladder and lawn tools are in the backyard, the kitchen appliances (inside and out) and bathtub are unclean including the floors which poses a potential health and safety risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
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Administrator will review regulations, conduct in-service training with staff and submit a copy of training agenda with staff signature to CCLD by 06/07/2022.
Type B
Section Cited
CCR
80075(g)
80075 Health Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review, the licensee did not comply with the section cited above. LPA was unable to inspect a complete first aid kit. A complete first aid kit was not present at the facility which pose a potential health and safety risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator to provide a copy or photo of the receipt and first aid kit to CCLD by 05/27/2022.
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: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


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