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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200991
Report Date: 06/23/2023
Date Signed: 06/23/2023 01:01:22 PM


Document Has Been Signed on 06/23/2023 01:01 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
E BAY DELTA AC/SC, 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:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Alberto Bernardino, AdministratorTIME COMPLETED:
01:15 PM
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On 6/23/2023 at 11:35 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. Administrator arrived at approximately 12:03 PM. LPA met with Administrator, Alberto and explained the purpose of the visit. The facility’s fire clearance was approved for 5 Non Ambulatory and 1 Bedridden.

LPA toured facility with Alberto 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 118 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 4/4/2023. First aid kit was observed to be complete.

Report continues on 809 C.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AGNES HOUSE
FACILITY NUMBER: 079200991
VISIT DATE: 06/23/2023
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/14/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate



No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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