<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440861
Report Date: 10/22/2022
Date Signed: 10/22/2022 01:08:12 PM


Document Has Been Signed on 10/22/2022 01:08 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:B-N RESIDENTIAL CARE HOMEFACILITY NUMBER:
011440861
ADMINISTRATOR:BAUTISTA, ALEJANDRIA N.FACILITY TYPE:
740
ADDRESS:4801 MICHELLE WAYTELEPHONE:
(510) 471-6229
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
10/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Irene Agamao, CaregiverTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/22/2022 at 11:15AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Irene Agamao, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Alejandria Bautista via telephone and was given approval for Caregiver to sign documents.

Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, backyard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 104.5 degrees Fahrenheit. Fire extinguisher last serviced on 8/16/2022.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the mitigation plan on file. LPA observed PPE and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: B-N RESIDENTIAL CARE HOME
FACILITY NUMBER: 011440861
VISIT DATE: 10/22/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809.

The following forms are to be updated and submitted to CCLD by 10/31/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC601E Emergency Disaster Plan
-Facility roster

LPA observed the following deficiencies:

-At 11:30AM, LPA observed facility did not have a minimum of 2-day perishable and 7-day non-perishable foods for residents.

-At 11:45AM, LPA observed R1 had a hospital bed with no doctor's order.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.


SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/22/2022 01:08 PM - It Cannot Be Edited

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: B-N RESIDENTIAL CARE HOME
FACILITY NUMBER: 011440861

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
87555 General Food Service
(b) The following food services requirements shall apply:
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having a minimum of 7-day non-perishable and 2-day perishable foods available for residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
1
2
3
4
Administrator agreed to purchase a minimum of 7-day non-perishable and 2-day perishable foods and submit a photo of foods and receipt to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on(observation and record review, the licensee did not comply with the section cited above in having a doctor's order for R1's hospital bed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
1
2
3
4
Administrator agreed to obtain a doctor's order for a hospital bed for R1 and submit a copy to CCLD by POC date.

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3