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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200407
Report Date: 06/24/2021
Date Signed: 06/24/2021 12:53:37 PM

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:BERMUDA RESIDENTIAL CARE HOMEFACILITY NUMBER:
079200407
ADMINISTRATOR:CHARMAINE C. COLLADOFACILITY TYPE:
740
ADDRESS:984 BERMUDA DRIVETELEPHONE:
(925) 278-2914
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 6DATE:
06/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Floredelina ComillasTIME COMPLETED:
01:10 PM
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On 6/24/2021 at 10:35 AM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with staff Floredelina Comillas to inform the purpose of visit. LPA called Administrator Charmaine Cruz to inform her that LPA is at the facility to conduct annual inspection, Administrator is not available during the visit, she gave permission to give copy of report to staff on duty. Facility has census of 6.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days.

Facility has enough 2-day perishable food and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan.

....Continued to LIC809C...
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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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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: BERMUDA RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200407
VISIT DATE: 06/24/2021
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LPA observed the following:
Facility does not documents daily COVID-19 symptom checks, and any change in condition for staff and residents –during the visit, facility staff created a new document to monitor covid19 symptoms for staff and residents. This is a technical violation, no deficiency cited.

Signs has not been posted at facility entrance with updates to visitor policy to notify of policies . Technical violation given; no deficiency cited. Staff posted covid19 posters during the visit.

Licensee/Administrator has not provided all staff with fit testing for N95 respirators. – this is a technical violation, no deficiency cited. Administrator will conduct fit testing for all staff and will provide training documentation to LPA by July 9, 2021.

No deficiency cited during the visit.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC809 (FAS) - (06/04)
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