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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200010
Report Date: 06/07/2023
Date Signed: 06/07/2023 03:12:51 PM

Document Has Been Signed on 06/07/2023 03:12 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:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Narciso BernardoTIME COMPLETED:
03:30 PM
NARRATIVE
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On this day at around 8:55 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct annual required inspection. LPA was met by staff Emerenciana Nicolas and explained the purpose of visit. Administrator Narciso Bernardo arrived at the facility at a later time.

The facility is a Level 3 home vendorized by the Regional Center of the East Bay (RCEB). It has an approved fire clearance for 6 ambulatory clients.

There was one client at the facility observed doing activities via zoom.

LPA inspected the facility inside and out including but not limited to client bedrooms, 2 bathrooms, kitchen, dining and backyard. Facility was observed clean and with sufficient lighting. There was no body of water observed. Hot water measured at 105 F in the kitchen. There was sufficient supply of perishable and non perishable foods observed. Fire extinguisher in the kitchen was observed full that was last inspected on 12/16/2022. Carbon monoxide and smoke detector were tested and observed functional.
Medications were observed locked in a cabinet in the hallway.

Facility has an infection control plan. Facility has a surety bond in the amount of $5,000.

At 10:25 am, LPA reviewed Medication Administration Record (MAR) and medications. At 10:45 am, LPA reviewed P & I money. At 11:20 am, LPA reviewed 3 resident files and 3 staff files. LPA interviewed 2 clients and 2 staff.

At 12:45 pm, LPA reviewed First aid kit. Last fire drill was conducted on 11/2022.
continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BERNARDO RESIDENTIAL FACILITY
FACILITY NUMBER: 019200010
VISIT DATE: 06/07/2023
NARRATIVE
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The following deficiencies were observed:
  • Client 1 (C1) Physician's Report indicates C1 is non ambulatory; approved fire clearance is all ambulatory only
  • C1 is non ambulatory but is occupying ambulatory room
  • surety bond in the amount of $5000 is not sufficient for the P&I money being handled ($7,488.61)
  • Client bed was observed caving in/not in good repair
  • Last fire drill was conducted on 11/2022

Deficiencies were cited per Title 22 California Code of Regulations (refer to Lic 809D). Failure to correct deficiencies by due date may result to civil penalty.



Exit interview was conducted with Administrator. A copy of this report and Appeal Rights were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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Page: 2 of 5
Document Has Been Signed on 06/07/2023 03:12 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/07/2023 at 02:21 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: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

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 in having one non ambulatory client which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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1. Licensee/Administrator will notify Union City Fire Department regarding non ambulatory client.
2. Licensee will submit to LPA request for a nonambulatory fire clearance.
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observation, the licensee did not comply with the section cited above in having a non ambulatory client without an approved non ambulatory fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Licensee will send in request for a non ambulatory fire clearance.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


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Document Has Been Signed on 06/07/2023 03:12 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/07/2023 at 02:21 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: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

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. LPA observed one client mattress caving in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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By POC date, Administrator will purchase a new mattress and send proof of purchase to CCL.
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

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. The last fire drill was conducted on 11/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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By POC date, Administrator will conduct fire drill and submit proof of training to CCL.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


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Document Has Been Signed on 06/07/2023 03:12 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/07/2023 at 02:37 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: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(c)Bonding
(b) All licensee, other than governmental entities, who are entrusted to care for and control clients' cash resources file for or have on file with the licensing agency, a bond...

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 above. Facility has surety bond in the amount of $5000 which is not sufficient to cover amount of cash being handled in the amount of $7488.61 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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By POC date, Administrator will obtain additional bond to cover amount of money being handled and will submit to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
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