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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804030
Report Date: 02/02/2023
Date Signed: 02/02/2023 12:57:15 PM


Document Has Been Signed on 02/02/2023 12:57 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: 23DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee, Anu DhawanTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 02/02/2023 to conduct a required - 1 year inspection. The inspection was focused on the infection control practices and procedures of this facility. LPA signed in and screened for COVID upon arrival. LPA met with licensee, Anu Dhawan.

LPA toured building and grounds which were clean and in good repair. Exits and walkways were free from obstructions. Fire extinguishers inspected were charged and current. Carbon monoxide and smoke detectors were present and operational throughout the facility. Toxins were locked and secured. Medications were locked and secured. Bathrooms had necessary grab bars and nonskid flooring. Facility has sufficient perishable and nonperishable food. High touch surface areas are disinfected daily. Facility has sufficient personal protective equipment to support a resident in isolation. LPA and licensee discussed resident and staff record keeping. Facility is considering turning one of the facility's wings into a locked memory care unit. LPA is requesting a written plan be submitted outlining the exact changes they wish to make.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 day's of today's inspection:

LIC 9020 Resident Roster
LIC 308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan
Evidence of Liability Insurance
LIC 500 Personnel Report

Exit interview conducted with licensee and a copy of this report emailed to facility. No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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