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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317677
Report Date: 07/19/2022
Date Signed: 07/19/2022 01:57:39 PM

Document Has Been Signed on 07/19/2022 01:57 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:B W HOMEFACILITY NUMBER:
390317677
ADMINISTRATOR:WEAVER, LARHONDAFACILITY TYPE:
735
ADDRESS:9148 DON RAMONTELEPHONE:
(209) 473-0980
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 0DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Rashaud WeaverTIME COMPLETED:
02:15 PM
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On 7-19-22 at 1:10pm, LPA Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the facility manager Rashaud Weaver and explained the purpose of the visit. Administrator was not present and unable to be reached.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility. There are currently no residents living in facility, as facility is currently under minor renovations including new flooring, paint, air conditioning unit, baseboards,and electrical outlets. Facility entry way leads to the kitchen. There is one bedroom off the living room area. 2 bedrooms are down the hallway. LPA also conducted the infection control domain tool.
The facility submitted a LIC 808 mitigation plan, which was approved. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads between 105*F and 120*F*F in the bathroom and room temperature reads 78*F. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 11/15/2021. LPA requested updated plan for renovation from Licensee. Facility manager stated residents will not move into facility until renovations are complete.

Per California Code of Regulations, Title 22, Division 6, no deficiencies were observed during this visit. Exit interview was held and a report was given to Facility Manager Rashaud Weaver.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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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