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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200010
Report Date: 04/09/2024
Date Signed: 04/09/2024 02:57:43 PM

Document Has Been Signed on 04/09/2024 02:57 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:
04/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Narciso BernardoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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LPA conducted a case management visit and met with Administrator Narciso Bernardo. During the course of investigation of complaint#15-AS-20240308105135, LPA reviewed records and interviewed staff 1 (S1).

Based on C1’s Physician’s Report, C1 needs assistance for all personal needs. Based on interview conducted with S1, S1 states C1 is able to brush own teeth and does not need supervision.

C1 was reported to have had two wiggly teeth (one of which C1 pulled out), inflamed gum and teeth that appear to be decaying. On 3/8/2024, C1 showed LPA one wiggly tooth. LPA observed at least two teeth that appeared black in color. C1’s last visit with the dentist was in October 2022.

Deficiency is cited Per Title 22 California Code of Regulations (refer to the attached Lic 809D).

Exit interview was conducted and Appeal Rights was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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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Document Has Been Signed on 04/09/2024 02:57 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 04/09/2024 at 02:26 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: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2024
Section Cited
CCR
80072(9)

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80072(9) Personal Rights
(9) To receive or reject medical care, or health-related services, except for minors and other clients for whom a guardian, conservator, or other legal authority has been appointed.

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The Administrator will update C1's Appraisal Need and Services and submit self-certification stating that staff have been assisting C1 with brushing teeth.
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This requirement is not met as evidenced by: Staff failed to assist C1 in brushing teeth resulting to C1 having 2 wiggly teeth (1 of which C1 pulled out) and 2 decaying teeth which poses an immediate risk to the health and safety of clients under care.
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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: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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