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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804115
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:13:26 PM

Document Has Been Signed on 04/14/2023 04:13 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PACIFIC GARDENS AT UNIVERSITYFACILITY NUMBER:
486804115
ADMINISTRATOR:BERNARDINO, KRISTINEFACILITY TYPE:
740
ADDRESS:118 UNIVERSITY AVETELEPHONE:
(760) 296-7562
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
04/14/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Kristine BernardinoTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Pre-Licensing Inspection and met with Applicant/Administrator, Kristine Bernardino.

Applicant has applied for a Change of Ownership at this location that currently has 5 residents in care. LPA/Lead Staff initiated a tour of the facility and made the following observations: Facility is a one story residence with five resident bedrooms, 2 bathrooms, living room, dining room, kitchen area, and the garage that has 1 staff bedroom and bathroom. All resident rooms are furnished per regulation. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in tested bathrooms read at 109, 111 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. The refrigerator was observed to be clean and there was plenty of perishable and Non perishable foods that appeared to be in good condition. Cleaning supplies are locked and not accessible to residents. The facility has a first aid kit available. Personnel records and clients records are stored in locked cabinet. Medication is centrally stored and locked.

Facility received an approved fire clearance dated October 17, 2022 that allows for 6 non-ambulatory residents. Fire Extinguishers were last serviced August 4, 2022. There are working smoke detectors and carbon monoxide detector. Required postings were observed, although the required Complaint Poster PUB475, is not the required size of 20x26. Administrator agreed to acquire the correct poster size.

Continued on LIC809C...
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PACIFIC GARDENS AT UNIVERSITY
FACILITY NUMBER: 486804115
VISIT DATE: 04/14/2023
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* Applicant to submit copy of Liability Insurance to Centralized Applications Bureau Analyst
Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation.
Component III was conducted today, with Applicant, Kristine Bernardino. Pre-Licensing is complete, with no deficiencies.
LPA will notify Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. Per Applicant/current Administrator, the facility submitted the Application with a request for a hospice waiver for 3 residents and currently has Dementia residents. Facility will need to have a dementia care plan in place and a Hospice Care plan.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
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