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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 02:16:50 PM

Document Has Been Signed on 01/22/2025 02:16 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: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:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Bernadette Dugan, Licensee TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 01/22/25 at 10:00 am Licensing Program Analysts (LPA) J. Clancy-Czuleger and A. Gomez arrived unannounced to do an annual inspection. LPA meet with Licensee Bernadette Dugan and explained the purpose of the visit.

LPAs inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade.

The following deficiency was observed during the visit:
Fire extinguishers has not been serviced since 2023
reporting requirements
dirty bathroom counter and sink
no night time staff
no staff
no emergency disaster plan

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
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)
Page: 1 of 5
Document Has Been Signed on 01/22/2025 02:16 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/22/2025 at 01:09 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having the tire extinguisher serviced since April 22, 2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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On or before due date, Licensee shall send proof to LPA of the purchase of new or the service of existing fire extinguishers and that they have scheduled the service of or replacement of existing fire extinguishers on an annual basis.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
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)
Page: 2 of 5
Document Has Been Signed on 01/22/2025 02:16 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/22/2025 at 01:09 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by having dirt and grime left around the sink of the bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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The facility agrees to clean the bathroom counter and sink. Proof of correction will be sent to CCLD by POC date
Type B
Section Cited
CCR
80061(b)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in by not sending incident reports to CCLD which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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The facility agrees to review the regulations and send a letter of self certification to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
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)
Page: 3 of 5
Document Has Been Signed on 01/22/2025 02:16 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/22/2025 at 01:09 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(a)
Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview record review, the licensee did not comply with the section cited above by only having one staff member who is the administrator and Licensee which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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The facility agrees to hire addtional staff. Proof of corrections will be sent to CCLD by POC date.
Type B
Section Cited
CCR
85065.6(b)
Night Supervision
(b) Employees providing night supervision from 10:00 p.m. to 7:00 a.m., as specified in (c) through (f) below, shall be available to assist in the care and supervision of clients in the event of an emergency, and shall have received training in the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having night time staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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The facility agrees to hire addtional staff. Proof of corrections will be sent to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
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)
Page: 4 of 5
Document Has Been Signed on 01/22/2025 02:16 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/22/2025 at 01:09 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above the kitchen counters and sink are not clean which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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The facility agrees to clean the kitchen. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not having a emergency and disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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 The facility agrees to complete an emergency and disaster plan and update it annually. Proof of correction will be sent to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
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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