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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600265
Report Date: 05/22/2024
Date Signed: 05/29/2024 11:40:08 AM

Document Has Been Signed on 05/29/2024 11:40 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:WILLIAMS BOARD & CARE HOME IIFACILITY NUMBER:
075600265
ADMINISTRATOR/
DIRECTOR:		FREDERICK WILLIAMSFACILITY TYPE:
735
ADDRESS:4229 TAFT STREETTELEPHONE:
(510) 237-2411
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 6CENSUS: 6DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Fredrick Williams, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 05/22/2024 at 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required Annual Inspection. LPA was greeted by a client at the entry and explained the purpose of the visit. Ida Moore, Care Staff contacted Frederick Williams, Administrator/Licensee (ADM) who was telephoned and arrived about 30 minutes later. Katrina Williams, co-administrator holds certificate # 6029382735, exp. 06/20/24.

LPA observed clients relaxing throughout the facility. COVID-19 screening signs, masks, gloves, and hand sanitizer remain present at the facility. LPA and ADM toured the facility including, but not limited to common areas, 2 (two) bathrooms, 3 (three) bedrooms, kitchen, garage and backyard. LPA observed mask, cough etiquette, social distancing and handwashing signs posted in the common area. ADM to post 20 seconds handwashing signs, replace garbage can in downstairs bathroom and provide paper towels when needed. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. Handwashing stations were equipped with handsoap, the hot water temperature in the shared residents' bathroom was measured at 107.9 degrees Fahrenheit (F.) and the facility's temperature was 69 F. Fire extinguisher was observed full and last inspected on 04/30/24. Smoke/Carbon Monoxide detectors were observed operational and first aid kit was complete.

The following forms are to be updated and submitted to CCLD on or before 06/05/24:
-LIC500 Personnel Report
-Client Roster
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610D Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)

...continued on LIC 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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Document Has Been Signed on 05/29/2024 11:40 AM - It Cannot Be Edited


Created By: Lisha Holmes On 05/22/2024 at 02:33 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: 05/22/2024

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 interviews, the licensee did not comply with the section cited above by the facility not being sanitary and in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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Licensee to provide photos of cleaned bathrooms #1 and #2, photos of cleaned bedroom walls and windows for #1, #2 and #3, photos of the carpeting for bedrooms #1, #2, and #3, and receipts for cleaning services and/ or rented devices.
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: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


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: WILLIAMS BOARD & CARE HOME II
FACILITY NUMBER: 075600265
VISIT DATE: 05/22/2024
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...continued from LIC 809.

The following forms are to be updated and submitted to CCLD on or before 06/05/24:
-Emergency Disaster Binder
-Emergency Disaster Drills


The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

LPA observed the following during course of inspection:
· Approximately at 10:45 AM, 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 in bathroom #1 and #2 upstairs.
· Approximately at 10:35 AM, LPA observed what appeared to be mold or mildew surrounding the entire window and on the walls in bedroom #1, #2, and #3, the window of the dining room, and the window of the living room with the window frame broken and weather stripping coming undone.
· Approximately at 10:25 AM, LPA observed that the floor carpeting in bedrooms #1, #2 and #3 needs to be shampooed in order to be cleared of spots, food particles, dust and debris.

Exit interview conducted, appeal rights and a copy of this report provided to Care Staff, Ida "Keisha" Moore.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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