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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200010
Report Date: 08/11/2022
Date Signed: 08/11/2022 03:43:09 PM

Document Has Been Signed on 08/11/2022 03:43 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BERNARDO RESIDENTIAL FACILITYFACILITY NUMBER:
019200010
ADMINISTRATOR:BERNARDO, NARCISOFACILITY TYPE:
735
ADDRESS:32800 REGENTS BLVD.TELEPHONE:
(510) 490-8278
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Narciso Bernardo, AdministratorTIME COMPLETED:
03:55 PM
NARRATIVE
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On 8/11/2022 at 9:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with caregiver, Emerenciana and informed her the reason for the visit. Also present during the inspection was Regional Center of the East Bay, Quality Assurance Specialist. Administrator, Narciso Bernardo arrived about an hour later.

Upon entry, staff did not conduct screening for LPA. LPA observed hand sanitizer at screening station along with a notebook where visitor writes down their name. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPA observed cough etiquette and signs & symptoms posted on bulletin board. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at bathrooms.

During record review, LPA observed visitors log and temperature log for clients. LPA observed facility has a copy of Mitigation Plan on file. LPA observed food supplies and paper supplies are sufficient.

During the facility outbreak, LPA L. Fontanilla observed staff was not wearing full PPEs and was only wearing N95 mask. S2 was wearing N95 mask over surgical mask.

At 9:25AM, LPA observed unlocked scissors and knives in the kitchen drawers. LPA also observed unlocked OTC medications, ointments, and vitamins in the dining cabinets. Staff locked up all the scissors, knives, OTC meds, ointments, and vitamins during inspection.

At 9:30AM, LPA observed medication cabinet was unlocked during inspection. Staff locked up cabinet during inspection. (Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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 13
Document Has Been Signed on 08/11/2022 03:43 PM - It Cannot Be Edited


Created By: Grace Luk On 08/11/2022 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BERNARDO RESIDENTIAL FACILITY
FACILITY NUMBER: 019200010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked knives, scissors, OTC medications, ointments, and vitamins which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Staff locked up the knives, scissors, OTC medications, ointments, and vitamins during inspection.

Deficiency cleared.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked medication cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Staff locked up the medication cabinet during inspection.

Deficiency cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 08/11/2022 03:43 PM - It Cannot Be Edited


Created By: Grace Luk On 08/11/2022 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BERNARDO RESIDENTIAL FACILITY
FACILITY NUMBER: 019200010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having lots of items that's waiting to be discarded including shoe racks, bins, old TVs on the side yard which poses a potential health and safety risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Administrator has agreed to remove all the items along the side yard and submit picture proof to CCLD by POC date.
Type B
Section Cited
CCR
85065.5(a)(1)
Day Staff-Client Ratio
(1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having insufficient staff which poses a potential health and safety risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Administrator has agreed to hire new staff and submit LIC500 to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 08/11/2022 03:43 PM - It Cannot Be Edited


Created By: Grace Luk On 08/11/2022 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BERNARDO RESIDENTIAL FACILITY
FACILITY NUMBER: 019200010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80064(a)(3)
Administrator Qualifications and Duties
(3) Knowledge of and ability to comply with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not reviewing current infection control guidelines and CCLD PINs which poses a potential health and safety risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Administrator has agreed to review all infection control PINs and other PINs. Administrator will submit a written statement of completion to CCLD by POC date.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having personnel file for S4 which poses a potential health and safety risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Administrator has agreed to create a personnel file for S4 and submit all forms to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 08/11/2022 03:43 PM - It Cannot Be Edited


Created By: Grace Luk On 08/11/2022 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BERNARDO RESIDENTIAL FACILITY
FACILITY NUMBER: 019200010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current needs and service plans for C1, C4, and C5 which poses a potential health and safety risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Administrator has agreed to obtain current needs and service plans for C1, C4, and C5 and submit copies to CCLD by POC date.
Type B
Section Cited
CCR
80072(a)(7)
Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(7) Not to be locked in any room, building, or facility premises by day or night.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a lock on one of the side gates which poses a potential health and safety risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Administrator removed the lock during inspection.

Deficiency cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
Page: 5 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/11/2022
NARRATIVE
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At 9:35AM, LPA observed one of the side gate to the facility had a lock on the self-closing latch. LPA observed the other side gate on the left side of the facility was unlocked. Administrator unlocked the side gate during inspection.

At 9:40AM, LPA observed side yard on the right side of the facility has lots of items that's waiting to be discarded including shoe racks, bins, old TVs, etc.

At 10:00AM, LPA observed S4 has been working during the outbreak, but did not have a personnel file at the facility. Administrator informed LPA that S4 does not have a file at the facility and will create a file for S4.

At 10:10AM, LPA observed facility does not have sufficient staffing. LIC500 and staff schedule stated that S3 was working on Saturdays and Sundays. However, administrator informed LPA that S3 came back from the East Coast on 8/9/2022. Upon arrival, LPA observed only S2 at the facility with 5 clients. S1 was on the schedule, but was not present when LPA arrived. There was no additional staff to cover for S1's schedule while S1 was out of the facility.

At 10:30AM, LPA observed C1, C4, and C5 does not have a current IPP or needs and service plan on file during record review.

At 10:45AM, LPA observed that administrator did not have knowledge on CCLD infection control guidelines and PINs. Administrator informed LPA that he was not update on PINs and did not review the latest PINs as the facility did not have positive cases until recently last month. Staff have not been FIT test. Staff did not have don/doff training and no documentation was observed. Administrator have not been updating staff or clients on latest infection control guidelines.

At 11:00AM, LPA was informed by administrator that the facility does not have an infection control plan. It was identified during the outbreak that facility did not have an infection preventionist identified.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 12 of 13
Document Has Been Signed on 08/11/2022 03:43 PM - It Cannot Be Edited


Created By: Grace Luk On 08/11/2022 at 02:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BERNARDO RESIDENTIAL FACILITY
FACILITY NUMBER: 019200010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(b)(2)
Infection Control Requirements
(2) All staff and volunteers providing direct care to a resident who has a communicable disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by staff not wearing proper PPEs during COVID-19 outbreak which poses a potential health and safety risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Administrator has agreed to obtain PPE training for all staff by either RCEB nurse or CCLD approved vendor. Administrator will submit certificate of completion to CCLD by POC date.
Type B
Section Cited
CCR
85095.5(c)(1)(A)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.
(1) The Infection Control Plan shall include all of the following:
(A) Identification of a staff position to perform the duties of an Infection Preventionist for the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having an infection preventionist identified which poses a potential health and safety risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Administrator has agreed to complete LIC9282 (infection control plan) and submit a copy to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
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