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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200991
Report Date: 07/18/2024
Date Signed: 07/31/2024 01:16:54 PM


Document Has Been Signed on 07/31/2024 01:16 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:
079200991
ADMINISTRATOR:BERNARDINO, ALBERTOFACILITY TYPE:
740
ADDRESS:1644 BECKNER CTTELEPHONE:
(925) 338-2399
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 0DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Mary Grace Bernardino, Staff (S1)
Alberto Bernardino, Administrator (ADM)
TIME COMPLETED:
03:00 PM
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On 07/17/24 at 1:20 PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S1) and spoke to administrator (ADM) and explained the purpose of the visit. ADM authorized S1 to act on his behalf and sign the reports. The facility’s fire clearance was approved for 5 Non Ambulatory and 1 Bedridden. LPA observed facility currently has no residents. ADM stated he is keeping the facility open and all annual fees current until the time they decide to accept new residents.

At 1:40PM, LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms. All outdoor and indoor passageways are kept free of obstruction. LPA observed a locked gate around the pool. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the bathroom was measured at 115 degrees Fahrenheit. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Cabinets for centrally stored medication and sharps were locked. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last purchased on 07/17/24. First aid kit was observed to be complete. The infection control leader is the administrator. LPA reviewed and interviewed 2 staff.

No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
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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