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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804030
Report Date: 07/20/2022
Date Signed: 07/20/2022 01:35:01 PM


Document Has Been Signed on 07/20/2022 01:35 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, THEFACILITY NUMBER:
286804030
ADMINISTRATOR:DHAWAN, BABITAFACILITY TYPE:
740
ADDRESS:2300 BROWN STREETTELEPHONE:
(510) 996-8520
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:72CENSUS: 19DATE:
07/20/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Licensee/Administrator, Babita DhawanTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 07/20/2022 to conduct a Post Licensing Inspection. LPA met with Licensee/Administrator, Babita Dhawan. Upon arrival LPA filled out a COVID screening form.

LPA toured building and grounds with Licensee/Administrator which were found to be clean and in good repair. Facility currently has 19 residents, 12 in memory care and 7 in assisted living. Facility has an approved hospice waiver for 15 residents, facility currently has 6 residents on hospice. Bedrooms were appropriately furnished. LPA measured water temperature in two locations accessible to residents. One reading was 109.7 degrees F and the second was 116.6 degrees F. Fire extinguishers inspected were last charged 04/08/2022. Carbon Monoxide detectors were observed throughout the facility. Doors are equipped with exit alarms. Facility has a sprinkler system and smoke detectors throughout the facility.

During the inspection LPA observed lunch being served in resident's bedroom as a COVID precaution. Facility is surveillance testing per CCL guidelines.

LPA reviewed 5 resident files. All resident files contained LIC 602s, Admission Agreements, and Need/Services Plans. LPA provided guidance to update admission agreements signed under previous license. LPA reviewed 4 staff files. LPA provided guidance on required staff training.

Exit interview conducted with Licensee/Administrator and a copy of the report printed for this facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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