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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200010
Report Date: 05/15/2024
Date Signed: 05/20/2024 08:52:52 AM

Document Has Been Signed on 05/20/2024 08:52 AM - 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:
05/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Narciso BernardoTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On this day at around 10:25 am, LPA Luisa Fontanilla arrived unannounced to conduct a case management visit and spoke with Administrator Narciso Bernardo.

LPA was informed by the Administrator that the facility is on covid outbreak status. 4 out of 5 clients and Administrator are all positive. The Administrator states the outbreak was reported to the Regional Center of the East Bay (RCEB) but failed to report to CCL.

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

A copy of this report was sent to the Administrator via email.
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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Document Has Been Signed on 05/20/2024 08:52 AM - It Cannot Be Edited


Created By: Luisa Fontanilla On 05/15/2024 at 11:11 AM
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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2024
Section Cited
CCR
80061(a)

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80061(a) Reporting Requirements
a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
This requirement is not met as evidenced by:
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The Administrator will report outbreak to CCL by end of day and will continue to update CCL until all positive cases are cleared.
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LPA arrived unannounced to conduct annual inspection but was informed that the facility is on outbreak but failed to report to CCL.
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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: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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