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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200224
Report Date: 05/11/2022
Date Signed: 05/11/2022 02:12:47 PM

Document Has Been Signed on 05/11/2022 02:12 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:BUENAVISTA HOME AT HERCULES BY THE BAYFACILITY NUMBER:
079200224
ADMINISTRATOR:RONALDO PEREZFACILITY TYPE:
735
ADDRESS:112 PEARCE STREETTELEPHONE:
(510) 724-3880
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 5DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Gemma Ferreria, CaregiverTIME COMPLETED:
02:30 PM
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On 05/11/2022 at 1:10pm Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct infection control inspection LPA met with Caregiver, Gemma Ferreria and explained the purpose of the visit. Administrator Ronaldo Perez arrived at 2:00pm.

During the Infection Control Inspection, LPA toured facility including but not limited to common areas, kitchen, bedrooms, and shared bathrooms. Front entrance, screening station, hand washing stations, backyard, and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility staff were observed wearing masks. Facility has a 30-day supply of PPE maintained at a central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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