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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200010
Report Date: 04/09/2024
Date Signed: 04/09/2024 02:56:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240308105135
FACILITY NAME:BERNARDO RESIDENTIAL FACILITYFACILITY NUMBER:
019200010
ADMINISTRATOR:BERNARDO, NARCISOFACILITY TYPE:
735
ADDRESS:32800 REGENTS BLVD.TELEPHONE:
(510) 324-2807
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
04/09/2024
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Narciso BernardoTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not ensuring that a resident is receiving access to dental healthcare
INVESTIGATION FINDINGS:
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On this day at around 2:10 pm, LPA Luisa Fontanilla arrived unannounced to deliver finding on the above allegation and met with the Administrator, Narciso Bernardo. LPA explained to Bernardo the purpose of the visit.
During the course of investigation, LPA interviewed the Administrator and C1’s Case Manager and reviewed records. Based on C1’s dental records, C1 was last seen for teeth cleaning in October 2022. No visits were recorded in 2023 and 2024. The Administrator states that C1 was supposed to have some dental works that needed to be done but were not completed due to insurance problem.

LPA interviewed C1’s Case Manager (CM) who states that the Administrator did not make the CM aware of C1’s dental insurance problem. And that the facility never communicated with CM regarding C1’s wiggly/decayed teeth.

continuation on Lic 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20240308105135
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BERNARDO RESIDENTIAL FACILITY
FACILITY NUMBER: 019200010
VISIT DATE: 04/09/2024
NARRATIVE
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Based on interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is cited on the attached Lic 9099D.

Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240308105135
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BERNARDO RESIDENTIAL FACILITY
FACILITY NUMBER: 019200010
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
CCR
85075(b)
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85075 Health-Related Services
(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.
This requirement is not met as evidenced by:
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The Administrator states: C1's teeth have been cleaned on 3/14, treatment for the gum started on 4/4/2024. C1's treatment will last until 1st box is used up then C1 needs to go back to the dentist. After treatment, C1's wiggly tooth will be pulled.
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The facility failed to assist C1 in meeting C1’s dental needs resulting to C1 having wiggly/decaying teeth which poses an immediate risk to health and safety of client under care.
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The Administrator will update CCL each time C1 has completed a dental appointment.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3