286804030-3-10-2022-21-AS-CARD-CCDU59-20220310141621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804030
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:16:32 PM

Document Has Been Signed on 03/10/2022 02:16 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BERKSHIRE, THE		FACILITY NUMBER:	286804030
ADMINISTRATOR:	DHAWAN, BABITA		FACILITY TYPE:	740
ADDRESS:	2300 BROWN STREET		TELEPHONE:	(510) 996-8520
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	72	CENSUS: 14	DATE:	03/10/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Lia Miller; Babita Dhawan		TIME COMPLETED:	02:30 PM

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At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced, to conduct a pre-licensing inspection due to an ownership change of this currently operating care facility for the elderly. LPA was screened for Covid-19 symptoms and temperature was recorded. LPA met with Administrator Lia Miller and Applicant Babita Dhawan. The facility is requesting a total capacity of 72 with 52 non-ambulatory and 20 bedridden residents. The facility has requested and received a hospice waiver for 15 residents.

The facility has a courtyard in the rear of the facility, and a closed-in outdoor patio in the center. Random rooms were inspected in the Assisted Living and memory care areas of the facility. The indoor temperature was comfortable. All personal accommodations were present in the inspected rooms.

LPA observed facility hallways and exits were unobstructed. Exits were clearly marked. Facility cleaners and toxins are stored in a locked housekeeping supply room. Housekeeping carts are lockable and were found to be locked while in use. LPA observed plenty of perishable and nonperishable foods. The kitchen and dining area was clean and well maintained. Water temperature measured within regulation between 105 and 120 degrees F in various resident bathrooms. LPA observed the facility has a hard wired fire alarm system, and has appropriate smoke and carbon monoxide alarms in place. Medication is centrally stored and locked in a dedicated medication room in the assisted living section of the building. Resident records are also kept locked and secure.

Continued on LIC809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BERKSHIRE, THE	FACILITY NUMBER: 286804030
	VISIT DATE: 03/10/2022

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The facility has multiple fire alarm pull stations with audio/visual alerts, and all resident bathrooms have push button alarms for alerting staff for assistance. All fire extinguishers were charged and inspected within the last 12 months. The facility has a functioning smoke detectors in all resident rooms and smoke detectors in hallways and common areas. There are also carbon monoxide detectors throughout the facility. The fire system is checked annually.

LPA and Applicant discussed the facility's emergency disaster preparedness plan for the individual facility needs and the disaster plan for a large scale disaster which may affect city/county. Facility has the required 7 days non-perishable and 2 days perishable food on hand.

LPA conducted the Component III Orientation with Applicant. Based on their knowledge shown, the Applicant has successfully completed the Component lll Orientation section of the application process.

Applicant provided evidence of Liability insurance at the time of visit.

This application is ready for submission to the Licensing Program Manager for review and approval of facility license.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

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