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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200603
Report Date: 01/22/2025
Date Signed: 01/22/2025 02:37:00 PM

Document Has Been Signed on 01/22/2025 02:37 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:OUR HOMEFACILITY NUMBER:
079200603
ADMINISTRATOR/
DIRECTOR:		DUGAN, BERNADETTEFACILITY TYPE:
735
ADDRESS:370 VERNAL DRIVETELEPHONE:
(925) 933-8706
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY: 6CENSUS: 2DATE:
01/22/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:37 PM
MET WITH:Licensee, Bernadette DuguanTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 1/22/2025 LPA's A Gomez and J Clancy-Czuleger conducted a case management visit while at the facility for complaints 15-AS-20240708085122 and 15-AS-20241227084412. LPAs met with Licensee/ Administrator Bernadette Dugan and explained the purpose of the visit.

While conducting the complaint investigation LPA's observed the following deficiencies:

  • Residents were left unsupervised

Upon arrival on LPA and AGPA observed that the Licensee was cleaning their yard while the clients were left unsupervised at the facility. Licensee also stated that they often leave the clients at the facility alone while they run errands.

***A Civil Penalty in the Amount of $250 is being assessed for repeat violation within a 12 month period***

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.



Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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 01/22/2025 02:37 PM - It Cannot Be Edited


Created By: Alona Gomez On 01/22/2025 at 01:40 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: OUR HOME
FACILITY NUMBER: 079200603

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/22/2025
Section Cited
CCR
80064(a)(2)

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(a)The administrator shall have the following qualifications:..(2) providing the type of care and supervision needed...with such clients.

This requirement was not met as evidenced by:
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By POC Licensee agrees to hire additional staff to continusly monitor clients and notify CCLD.
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Based on interviews the Licensee did not comply with the section cited above by leaving clients unsupervised which poses an immediate safety risk to clients in 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:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
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