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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804162
Report Date: 10/27/2023
Date Signed: 10/27/2023 04:04:10 PM


Document Has Been Signed on 10/27/2023 04:04 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 ON HAWKESBURYFACILITY NUMBER:
486804162
ADMINISTRATOR:BERNARDINO, KRISTINEFACILITY TYPE:
740
ADDRESS:120 HAWKESBURY WAYTELEPHONE:
(760) 296-7562
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
10/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Myla Grace AlcaldeTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Pre-Licensing Inspection and met with care staff, Myla Grace Alcalde. Applicant/Administrator, Kristine Bernardino was unavailable during the inspection.

Applicant has applied for a Change of Ownership at this location and currently has 6 residents in care. LPA/Lead Staff initiated a tour of the facility and made the following observations: Facility is a one story residence with four resident bedrooms, 3 bathrooms, living room, dining room, kitchen area, and the garage. All resident rooms have most of the required furnishings, but are lacking lamps in resident bedrooms. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in tested bathrooms read at 115, 117 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, LPA removed some vegetable items that were starting to go bad. Cleaning supplies are locked and not accessible to residents. Personnel records and resident records are stored in locked cabinet. Medication is centrally stored and locked.

Facility received an approved fire clearance dated August 8, 2023 that allows for 6 non-ambulatory residents and there is no approval for bedridden as the facility recently removed the fire sprinklers with approval from the fire department. Fire Extinguishers were last serviced May 25, 2023. There are working smoke detectors and carbon monoxide detector. Required postings were observed, but LPA advised facility to post a copy of the facilities Admission Agreement.
During todays visit LPA was unable to conduct Component III with licensee because they were out of town and LPA will need to return to complete.


continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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 ON HAWKESBURY
FACILITY NUMBER: 486804162
VISIT DATE: 10/27/2023
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 Facility will also need to remove extra garbage items form the back yard, correct all 3 auditory door alarms in both sliding doors and front door that were not working.
LPA also requested the facility to get sliding doors serviced so that they open smoothly, as the doors were tight to open.

LPA also removed a rod with a curtain in the master bedroom and informed facility, the master bedroom bathroom may only be used by the 2 residents that the room is used by.

Pre licensing inspection is not complete and corrections are needed, along with completion of Component III with licensee.

no citations issued to this pre-licensing application.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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