019200010-5-14-2025-15-AS-LFOA-DGNRZR-20250514132823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200010
Report Date: 05/14/2025
Date Signed: 05/14/2025 01:28:49 PM

Document Has Been Signed on 05/14/2025 01:28 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 FACILITY		FACILITY NUMBER:	019200010
ADMINISTRATOR/ DIRECTOR:	BERNARDO, NARCISO		FACILITY TYPE:	735
ADDRESS:	32800 REGENTS BLVD.		TELEPHONE:	(510) 324-2807
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY: 6		CENSUS: 5	DATE:	05/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Emerenciana Nicolas/Narciso Bernardo		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day at around 10:30 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 12:30 pm. 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. During the visit, LPA inspected the facility inside and out including but not limited to client bedrooms, 2 bathrooms, kitchen, dining area, garage and backyard. Facility was observed clean and with sufficient lighting. There was no body of water observed. Hot water measured at 117 degrees Fahrenheit 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 12/21/2024. 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. At around 11:10 am, LPA reviewed P&I money and log with Nicolas. The facility has surety bond sufficient to cover amount of cash being handled at one time. At 11:20 am, LPA reviewed medications and Medication Administration Record (MAR). At around 11:50 am, LPA reviewed 5 client files and 2 staff files. All staff are fingerprint cleared and associated to the facility. continuation on Lic 809C

NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Luisa Fontanilla
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 05/14/2025

NARRATIVE

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The following deficiencies were observed:

a bottle of expired medication unlocked under the sink
carpet in Rooms #1 and #4 were observed stained
weeds in the backyard to be approximately one foot tall
couch in the dining area was observed ripped
both staff have expired First aid/CPR training
last fire drill was conducted in October 2024

Deficiencies are cited from Title 22 California Code of Regulations, and listed on Lic 809D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

The following documents will be submitted to CCL by Monday, May 19, 2025:

infection control plan
Liability insurance
Surety bond
Emergency Disaster Plan
Lic 500
Client Roster
Vehicle registration, insurance and driver's license

Exit interview was conducted with Bernardo, Appeal Rights and a copy of this report were provided.

NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Luisa Fontanilla
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/14/2025 01:28 PM - It Cannot Be Edited

Created By: Luisa Fontanilla On 05/14/2025 at 01:05 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: 05/14/2025

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not locking a bottle of expired medication which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/14/2025
	Plan of Correction
1 2 3 4	Staff locked the expired medication during the visit. This deficiency is cleared.

Type A

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviews conducted, the licensee did not comply with the section cited above in not having any staff with current First aid and CPR which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2025
	Plan of Correction
1 2 3 4	By POC date, both the Administrator and staff will complete First aid and CPR training and submit proof 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.

	Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:

	Luisa Fontanilla
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 05/14/2025 01:28 PM - It Cannot Be Edited

Created By: Luisa Fontanilla On 05/14/2025 at 01:05 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: 05/14/2025

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having weeds about one foot tall, couch that is ripped and stained carpets in Rooms 1 and 4 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/28/2025
	Plan of Correction
1 2 3 4	By POC date, the Administrator will remove weeds in the backyard, shampoo carpets and replace couch and submit proof of correction by POC date.

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
1 2 3 4	Based on , the licensee did not comply with the section cited above in not having fire drill on a quarterly basis which poses/posed a potential health, safety or personal rights risk to persons in care. Last fire drill was conducted in October 2024.
	POC Due Date: 05/19/2025
	Plan of Correction
1 2 3 4	The Administrator will conduct fire drill and submit proof to CCL 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.

	Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:

	Luisa Fontanilla
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC809 (FAS) - (06/04)

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