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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201047
Report Date: 02/10/2023
Date Signed: 02/10/2023 07:00:27 PM

Document Has Been Signed on 02/10/2023 07:00 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:AGNES HOUSEFACILITY NUMBER:
079201047
ADMINISTRATOR:BERNARDINO, ALBERTOFACILITY TYPE:
740
ADDRESS:1660 ARKELL RDTELEPHONE:
(925) 482-0601
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
02/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Gladys EnriquezTIME COMPLETED:
07:30 PM
NARRATIVE
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On 02/10/2023, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced complaint investigation. The LPA met with Assistant Administrator Gladys Enriquez.

During his inspection, the LPA discovered that the current facility Administrator is not at the facility an adequate amount of time each week for which they were cited (refer to LIC 9099D).

Exit interview conducted and copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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 2
Document Has Been Signed on 02/10/2023 07:00 PM - It Cannot Be Edited


Created By: James Sampair On 02/10/2023 at 06:16 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: AGNES HOUSE
FACILITY NUMBER: 079201047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.175(b)
(b) In order to assure the opportunity for complaints to be made directly to the owner, licensee, or person designated by the owner or licensee, and to provide the opportunity for the owner, licensee, or person designated by the owner or licensee to meet residents and learn of problems in the neighborhood, any facility with a nonresident owner shall establish a fixed time on a weekly basis when the owner, licensee, or person designated by the owner or licensee will be present.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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Licensee shall appoint persons of appropriate skill and training by the due date to serve as Administrator of this and all of the facilities under which he is licensed to provide adequate time (minimum 20 hours per week to work solely as an admiinitrator) to fulfill the regulation above.
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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
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