<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200850
Report Date: 04/04/2022
Date Signed: 04/04/2022 12:58:08 PM


Document Has Been Signed on 04/04/2022 12:58 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:GABRIEL'S HOUSE 2FACILITY NUMBER:
079200850
ADMINISTRATOR:BERNARDINO, JANE PFACILITY TYPE:
740
ADDRESS:3105 CONCORD BLVDTELEPHONE:
(925) 470-7160
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 5DATE:
04/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Jane Bernadino, AdministratorTIME COMPLETED:
01:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/04/2022 at 12:22 pm LPA J. CLancy-Czuleger arrived unannounced to conduct a case management visit regarding a report that was submitted on 3/21/2022. LPA met with Administrator, Jane Bernadino and explained the purpose of the visit.

During the visit LPA spoke and reviewed incident with Administrator. The Administrator stated that the Resident (R1) had been experiencing weakness and chills prior to the facility calling 911. R1 passed away while at the hospital and the family did not disclose the cause of death to the facility.

AM125 Death Report CM30.pdfAM125 Death Report CM30.pdf

Exit interview conducted.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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 1