<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200010
Report Date: 09/16/2022
Date Signed: 09/16/2022 05:38:53 PM

Document Has Been Signed on 09/16/2022 05:38 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:
09/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Narciso Bernardo, AdministratorTIME COMPLETED:
05:50 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 9/16/2022 at 5:00PM, Licensing Program Analysts (LPAs) G. Luk and P. Watson arrived unannounced to conduct a Case Management visit. LPAs met with Administrator, Narciso Bernardo.

While LPAs was at the facility for another visit, LPAs observed the following deficiency:

- LPAs observed unlocked paints and gloss in the backyard. Administrator locked up the paints and gloss during inspection.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency 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: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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 2
Document Has Been Signed on 09/16/2022 05:38 PM - It Cannot Be Edited


Created By: Grace Luk On 09/16/2022 at 05:17 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: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2022
Section Cited
CCR
80087(g)

1
2
3
4
5
6
7
Buildings and Grounds. Disinfectants,...poisons... and other items that could pose a danger...shall be stored where inaccessible to clients. This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator locked up paints and gloss during inspection.


Deficiency cleared.
8
9
10
11
12
13
14
Based on observation, licensee did not comply with the section cited above by having unlocked paints and gloss which poses an immediate health and safety risk to the persons in care.
8
9
10
11
12
13
14
Civil penalty of $250 is being assessed for repeat violation.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2