<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201047
Report Date: 04/10/2024
Date Signed: 04/10/2024 05:01:51 PM


Document Has Been Signed on 04/10/2024 05:01 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
OAKLAND ASC, 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:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Alberto BernardinoTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/10/2024 at 1:30 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Caregiver Ryan Belen. Administrator (ADM) Alberto Bernardino arrived at approximately 2:00 PM.

LPA toured the interior and exterior of the facility. LPA inspected the kitchen, dining area, restrooms, community living spaces, bathrooms, resident rooms, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the living room was 75.6 degrees Fahrenheit at 1:55 PM. Fire extinguisher was fully charged and last replaced on 3/21/2024. Carbon monoxide and smoke detectors were fully operational. The LPA observed that there were no bodies of water at the facility. The LPA observed postings in the facility which included: complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council, and Rights to Family Council.

An administrator is on site more than the minimum of 20 hours a week to ensure that proper business operations are being conducted. The LPA reviewed records of 5 residents. The LPA interviewed 2 staff members and 2 residents.

No citations issued during this visit.

Annual inspection incomplete. LPA will return to complete inspection on a future date.

Exit interview conducted with ADM and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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 1