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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200603
Report Date: 08/07/2024
Date Signed: 08/07/2024 05:34:02 PM

Document Has Been Signed on 08/07/2024 05:34 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:
08/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Licensee, Bernadette DuganTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
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On 8/7/2024 LPA's A Gomez and J Clancy-Czuleger conducted a case management visit while at the facility for complaint 15-AS-20240708085122. 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:
  • Administrator not providing supervision to residents
  • Administrator does not have a current administrator certificate.
  • Residents do not have files
  • Administrator does not have staff file
  • Staff are not first aid trained/CPR
  • The facility does not have an updated emergency disaster plan
  • The kitchen and dining area had dirty dishes
  • Residents did not have access to personal care items
  • Expired food found in fridge


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: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 6
Document Has Been Signed on 08/07/2024 05:34 PM - It Cannot Be Edited


Created By: Alona Gomez On 08/07/2024 at 03:59 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: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
CCR
80066(a)(12)(B)1.

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(a) The licensee shall ensure that personnel records are maintained...(12)For employees...(B)Documentation.... 1.For Certified Administrators, a copy of their current and valid Administrator Certification
This requirement was not met as evidenced by:
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Mandatory meeting to be held at a later date.
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Based on record review the Licensee did not comply with the section cited above by not having a valid Administrators certificate wich poses a potential personal rights risk to clients in care.
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Type B
08/20/2024
Section Cited
CCR80070(a)

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(a)The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
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Mandatory meeting to be held at a later date.
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Based on record review the Licensee did not comply with the section cited above by not having any current client records wich poses a potential personal rights 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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/07/2024 05:34 PM - It Cannot Be Edited


Created By: Alona Gomez On 08/07/2024 at 04:07 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: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
CCR
80066(a)

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(a)The licensee shall ensure that personnel records are maintained... Each personnel record shall contain the following information:

This requirement was not met as evidenced by
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Mandatory meeting to be held at a later date.
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Based on record review the Licensee did not comply with the section cited above by not having any current staff records wich poses a potential personal rights risk to clients in care.
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Type B
08/20/2024
Section Cited
CCR80064(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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Mandatory meeting to be held at a later date.
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Based on interview and observations the Licensee did not comply with the section cited above by not having adequete supervision for clients in care which poses a potential 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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/07/2024 05:34 PM - It Cannot Be Edited


Created By: Alona Gomez On 08/07/2024 at 04:15 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: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
CCR
80075(f)

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(f)Staff responsible for providing direct care and supervision shall receive training in first aid from ... American Red Cross.

This requirement was not met as evidenced by
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Mandatory meeting to be held at a later date
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Based on recorde review the Licensee did not comply with the section cited above by not having any current first aid or cpr training on record for staff which poses a potential safety risk to persons in care.
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Type B
08/20/2024
Section Cited
CCR80087(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by
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By POC date the facility agrees to clean the residents living space and send proof of correction to CCLD
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Based on recorde review the Licensee did not comply with the section cited above by dirty dishes being left on the table counters and in the sink which poses a potential personal rights risk to persons 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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2024 05:34 PM - It Cannot Be Edited


Created By: Alona Gomez On 08/07/2024 at 04:21 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: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2024
Section Cited
CCR
85088(c)

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(c) The licensee shall ensure... maintenance of personal hygiene

This requirement was not met as evidenced by
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By POC date the facility agrees to buy personal care items for residents including shampoo and bodywash and notify CCLD
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Based on observations the Licensee did not comply with the section cited above by the residents do not have access to shampoo or bodywash which poses a potential personal rights risk to clients in care.
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Type B
08/09/2024
Section Cited
CCR80076(a)(1)

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(a) In facilities providing meals...(1)All food shall be safe and of the quality...and served in a safe and healthful manner.

This requirement was not met as evidenced by
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By POC date the facility agrees to remove expired food from the facility. Proof of correction will be sent to CCLD
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Based on observations the Licensee did not comply with the section cited above by an expired box of beets in the fridge which poses a potential personal rights 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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/07/2024 05:34 PM - It Cannot Be Edited


Created By: Alona Gomez On 08/07/2024 at 04:32 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: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
CCR
80068.5(a)

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(a) Except for children's residential facilities, the licensee may, upon 30 days written notice to the client…following reasons:

This requirement was not met as evidenced by:
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Mandatory meeting to be held at a later date.
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Based on interview the administrator verbally threatening residents with eviction which poses a potential personal rights 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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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