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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440861
Report Date: 11/08/2021
Date Signed: 11/08/2021 03:21:51 PM

Document Has Been Signed on 11/08/2021 03:21 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,
, CA
FACILITY NAME:B-N RESIDENTIAL CARE HOMEFACILITY NUMBER:
011440861
ADMINISTRATOR:BAUTISTA, ALEJANDRIA N.FACILITY TYPE:
740
ADDRESS:4801 MICHELLE WAYTELEPHONE:
(510) 471-6229
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Alejandra Bautista, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Tobola arrived unannounced to conduct a Required - 1 Year inspection and met with Administrator, Alejandra Bautista (AB). The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for Elderly. Facility provides care for 5 residents, none of which are on hospice and some of which with a diagnosis of dementia.

LPA toured facility and grounds with Administrator and observed COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Staff follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test within 72 hours. Staff clean and disinfect the facility twice daily. Administrator stated high touched surface areas are disinfected after each use, such as the bathroom and kitchen area. Resident rooms and common areas have disinfecting wipes and hand sanitizer available. Bathrooms are equipped with liquid soap, paper towels and touch free operated garbage cans. Staff understand hand sanitizer should not be placed in the rooms of residents who lack hazard awareness and impulse control. Facility submitted a mitigation program plan, and plan has been reviewed. LPA reviewed training records and found all caregivers to have completed PPE training and have been N-95 Fit tested. In addition, all staff have current CPR & 1st Aid Training.

In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. No accessible bodies of water or fire safety hazards observed. Fire Extinguishers were found to be charged and serviced 8/17/2021. Smoke and Carbon monoxide detectors were tested and fully operational.
There was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit.
Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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
CCLD Regional Office,
, CA
FACILITY NAME: B-N RESIDENTIAL CARE HOME
FACILITY NUMBER: 011440861
VISIT DATE: 11/08/2021
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LPA requested the following updated documents to be submitted to CCLD by 11/12/2021:
  • Liability Insurance
  • LIC500 Personnel Report
  • LIC610 Emergency Disaster Plan

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
Due to printer malfunction, this report was emailed to Administrator.

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC809 (FAS) - (06/04)
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