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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804030
Report Date: 04/12/2024
Date Signed: 04/12/2024 04:29:05 PM


Document Has Been Signed on 04/12/2024 04:29 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
SANTA ROSA RO, 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: 21DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrators, Lia Miller and Babita DhawanTIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced at approximately 9:30AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit, Administrators, Lia Miller and Babita Dhawan arrived shortly after.

LPAs initiated a tour of the facility around 9:45AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 111, 108, 107, 110 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked.

Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the pantry. Personal Protective Equipment is stored in PPE closet. Fire extinguishers were last serviced March 27, 2024. Facility has combination smoke and carbon monoxide detectors as well as a sprinkler system that is serviced by an outside vendor. Most recent fire/disaster drill was conducted 02/07/2024.

Five staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Staff have required training. Administrator Certificate for Administrator, Lia Miller (6025709740) on the departments pending list. Medications and medication records were reviewed. LPAs observed 24 hours of pre poured medications. LPA and Administrators discussed that meds are no longer to be pre poured.

Continued on LIC809C
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BERKSHIRE, THE
FACILITY NUMBER: 286804030
VISIT DATE: 04/12/2024
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Continued from LIC809

Administrator to submit updates of the following documents by 05/12/2024:
LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 9020 Register of Residents

Emergency Disaster Plan (If any changes)
Infection Control Plan (If any changes)

No deficiencies cited during inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on forms confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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