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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440861
Report Date: 11/22/2024
Date Signed: 11/22/2024 11:12:10 AM

Document Has Been Signed on 11/22/2024 11:12 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:B-N RESIDENTIAL CARE HOMEFACILITY NUMBER:
011440861
ADMINISTRATOR/
DIRECTOR:
BAUTISTA, ALEJANDRIA N.FACILITY TYPE:
740
ADDRESS:4801 MICHELLE WAYTELEPHONE:
(510) 471-6229
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Alejandria Bautista, AdminstratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 11/22/24 around 8:45am. Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection and met with Alejandria Bautista and explain the purpose of the visit.

LPA inspected the facility inside and out including but not limited to resident rooms, bathrooms, common areas and backyard.

Facility has an approved fire clearance for 6 non ambulatory residents. Hot water measured at 108 Fahrenheit in the kitchen faucet. There was sufficient supply of perishable and non-perishable foods. Hygiene products were observed available. Sheets, towels, linen and warm blankets were available. First aid kit was complete. Fire extinguisher appeared full and was last serviced on 8/14/24. Fire Drill last conducted on 9/10/24. Liability Insurance 6/29/24 to 6/29/25. Emergency Disaster plan last posted on 2/11/24. Medications were observed locked in a cabinet in the hallway. Chemicals were locked in the garage. Bathrooms have grab bars and non-skid mats. Exit doors all have working auditory signals. Passageways and hallways were free of obstruction. First aid kit was complete.

At 9:45am, LPA reviewed 3 staff files and 6 resident files. Staff are fingerprint cleared and have current first aid and CPR training. Administrator certificate is current. At 10:45am, LPA reviewed medication and log.

No deficiencies noted for today's visit. Exit interview is conducted, and a copy of this report is provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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