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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508727
Report Date: 10/04/2024
Date Signed: 10/04/2024 11:40:45 AM


Document Has Been Signed on 10/04/2024 11:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:B & B RESIDENTIAL FACILITIES, INC.FACILITY NUMBER:
410508727
ADMINISTRATOR:SLAVA AND ANTE BULJANFACILITY TYPE:
740
ADDRESS:15 W. 38TH AVENUETELEPHONE:
(650) 345-6580
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:7CENSUS: 7DATE:
10/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator/Licensee - Ante BuljanTIME COMPLETED:
12:00 PM
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On 10/04/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with administrator/licensee Ante Buljan and explained the purpose of today's visit. There are currently 7 residents in care and 4 staff present. This is a multi level facility. The second floor is where the licensee resides. licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 5 hospice residents. Room 4 is the only cleared bedridden room. There are 3 hospice residents as of today's inspection visit.

The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site per the caregivers. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in a drawer next to the sink. Perishable and non-perishable food items are observed as being in place meeting both the 2 day fresh food supply and 7 day emergency food supply requirement. There is an additional refrigerator/freezer in the garage area which carries additional food supplies for resident use. PPE and incontinence supplies are also stored in the garage area and observed as in place. First aid kits are observed as complete with required items stored in the kitchen of the facility. Medications are observed to be locked in the kitchen in a kitchen cabinet. LPA observed at least two fire extinguishers in place which are currently within operating range, hard wired smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating/air conditioning. LPA also observed two fire pull stations in the rear and front of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Emergency disaster drill last conducted on July 22, 2024 Water temperature was measured at 107F. Cleaning supplies are observed to be locked in the kitchen below the sink and the garage. LPA observed the laundry room, and both laundry and dryer are operational.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: B & B RESIDENTIAL FACILITIES, INC.
FACILITY NUMBER: 410508727
VISIT DATE: 10/04/2024
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LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. Shower floors are equipped with non-skid mats or flooring. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 5 resident file and 4 staff files, which are all current. Administrator certificates are current for licensee expiring 01/10/2025.

The following updated forms are requested to be submitted to CCLD by 10/11/2024:

• Copy of updated Administrator Certificates
• Copy of liability insurance
• LIC308 Designation of responsible staff person
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property

There are no citations issued on this day. Report is reviewed with the licensee Ante Buljan and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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