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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200990
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:16:15 PM

Document Has Been Signed on 10/19/2023 04:16 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:B & B RESIDENTIAL CARE HOMEFACILITY NUMBER:
079200990
ADMINISTRATOR:CHERYL SMITHFACILITY TYPE:
735
ADDRESS:320 RIPLEY AVETELEPHONE:
(707) 332-5920
CITY:RICHMONDSTATE: CAZIP CODE:
94801
CAPACITY: 4CENSUS: 2DATE:
10/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver Adraine TrappsTIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/19/2023 at 09:15 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the initial 10-day complaint investigation. Upon entry, LPA informed Caregivers Maria Benitez and Adraine Trapps, and Licensee Cheryl Smith was then informed by phone of the purpose of the visit.

During the investigation, the LPA observed a deficiency unrelated to the complaint and issued 1 Type-A citation (details in LIC809-D).

Exit interview conducted with Caregiver Adraine Trapps. A copy of this report was provided via email to the Licensee.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 10/19/2023 04:16 PM - It Cannot Be Edited


Created By: James Sampair On 10/19/2023 at 01:34 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: B & B RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200990

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions ... and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Licensee shall: (1) remove disinfectants, cleaning solutions, and other dangerous items from the cabinet, (2) repair doors so they stay shut, and (3) add a clasp and lock to the doors if the intention is to store potentially dangerous items there in the future.
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Based on observation, the licensee did not comply with the section cited above. The hallway storage adjacent to bathroom containing disinfectants and cleaning solutions was neither closed nor locked.
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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:Bennett Fong
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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