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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200010
Report Date: 10/06/2023
Date Signed: 10/06/2023 02:48:45 PM

Document Has Been Signed on 10/06/2023 02:48 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:
10/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Narciso BernardoTIME COMPLETED:
03:00 PM
NARRATIVE
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On this day at approximately 12:35 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator Narciso Bernardo. LPA explained to Administrator the purpose of the visit.

During the visit, LPA went over with the Administrator violations issued by the Fire Department. At around 12:45pm, Fire Code Compliance Officer Joe Villarreal arrived at the facility and explained to the Administrator fire inspection corrections report. He also informed Administrator that the Building Department will be contacting the facility in connection with the shed and smoke detectors.

Administrator will submit to CCL by Monday, October 9, 2023 Lic 500 to indicate an awake night staff until facility clears from the fire department.

Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Administrator and Appeal Rights was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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 3
Document Has Been Signed on 10/06/2023 02:48 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 10/06/2023 at 01:50 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: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2023
Section Cited
CCR
80086(a)

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Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This requirement is not met as evidenced by:
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1.City Building Department was made aware and will contact the facility. Administrator will provide CCL update.
2. Administrator will submit updated sketch including the shed, gates and fence and submit to CCL.
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A shed 18 inches away from the wall was constructed on the side yard without notifying CCL and without approved city permit/fire clearance.
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Type A
10/07/2023
Section Cited
CCR80087(c)

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Buildings and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
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Administrator will 1)remove all furnishing blocking exit window in Room 4 2) will fix side gate to swing outward and 3) remove all sticks/wood blocking windows.
Photo proof will be submitted to CCL.
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1. Room #4 window was observed blocked with furnishings.
2. Side gate was observed swinging inward
3. Wood and sticks were observed blocking windows from opening

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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: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/06/2023 02:48 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 10/06/2023 at 02:22 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: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2023
Section Cited
CCR
80087(a)

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Buildings 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:
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By POC date, Administrator ensure that all doors and windows slide smoothly. And that fire extinguishers will get inspected.
LPA will conduct POC visit to verify.
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1. Sliding doors and windows do not open easily which poses a potential risk to health and safety of clients.
2. Fire extinguishers were observed purchased on 12/16/22 but do not have inspection tags.
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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: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023


LIC809 (FAS) - (06/04)
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