<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600657
Report Date: 07/25/2022
Date Signed: 07/26/2022 08:45:38 AM


Document Has Been Signed on 07/26/2022 08:45 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:B & B RESIDENTIAL FACILITIES, INC.FACILITY NUMBER:
415600657
ADMINISTRATOR:BULJAN, ANTEFACILITY TYPE:
740
ADDRESS:3824 BERESFORD STREETTELEPHONE:
(650) 345-4095
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Noralee ReyesTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms, each with a half bathroom, and a staff bedroom, plus 1 common full bathroom, kitchen/dining area, living room..
The upper level has a separate entrance and is not used as part of the RCFE. It is a rental unit and currently occupied by someone that is fingerprint cleared. There is a 1 car garage that is used for storage, and a laundry room. No accessible bodies of water are present.
Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, in addition to health screenings, TB test results, and valid first-aid training. Ante Buljan and Noralee Reyes are certified RCFE administrators (x 1/23 and 9/23) that oversee facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 8/15/22:

• LIC 309 Administrative Organization
• LIC 308 Designation of Administrative Responsiblilty
• LIC 500 Personnel REport
• Current liability insurance

Updated Emergency Disaster Plan (LIC 610E) is provided to LPA today.
No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.
See 4 Advisory Notes given to Ms. Reyes for additional information.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1