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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200010
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:24:00 PM

Document Has Been Signed on 06/12/2024 03:24 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/
DIRECTOR:		BERNARDO, NARCISOFACILITY TYPE:
735
ADDRESS:32800 REGENTS BLVD.TELEPHONE:
(510) 324-2807
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Narciso BernardoTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On this day at around 12:05 pm, 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 during the visit.

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 97.1 in the kitchen and 95.5 Fahrenheit in the bathroom. There was sufficient supply of perishable and non perishable foods observed. Fire extinguisher in the kitchen was observed full that was last inspected on 10/11/2023. Carbon monoxide and smoke detector were tested and observed functional. Medications were observed locked in a cabinet in the hallway. First aid kit was observed complete and current.

Facility has an infection control plan. Last earthquake/fire drill was conducted on May 15, 2024.

At around 1pm, LPA reviewed 5 client files and 3 staff files. All staff are fingerprint cleared and associated to the facility. They have current first aid and CPR training. At around 2pm , LPA reviewed medication and Medication Administration Record (MAR). At 2:15 pm, LPA reviewed P&I money and log with Nicolas. The facility has $7,000 amount of surety bond. Actual cash being handled is $9,352.47.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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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: 06/12/2024
NARRATIVE
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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: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 06/12/2024 03:24 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/12/2024 at 02:54 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: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(b)


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 in not having sufficient amount of bond tohandle cash which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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By POC date, Administrator will submit to CCL surety bond with the sufficient amount of coverage to handle cash.
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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2024 03:24 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/12/2024 at 02:57 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: 06/12/2024

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 in having screw drivers unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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By POC date, the Administrator will lock all screw drivers and notify CCL via email.
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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/12/2024 03:24 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/12/2024 at 02:57 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: 06/12/2024

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 in having ripped blinds/screen door/windows, fence leaning, cobwebs on windows, etc which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
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By POC date, Administrator will get things fixed and submit photo proof to CCL.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 in not having hot water within 105-120 range which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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The Administrator will adjust hot water within range and notify CCL via email once completed.
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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/12/2024 03:24 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/12/2024 at 02:57 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: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

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 in not having a shaded area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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The Administrator will provide a shaded outdoor area and submit photo proof to CCL by POC date.
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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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