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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201047
Report Date: 04/26/2023
Date Signed: 04/26/2023 05:23:54 PM


Document Has Been Signed on 04/26/2023 05:23 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:
079201047
ADMINISTRATOR:BERNARDINO, ALBERTOFACILITY TYPE:
740
ADDRESS:1660 ARKELL RDTELEPHONE:
(925) 482-0601
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Alberto BernardinoTIME COMPLETED:
06:00 PM
NARRATIVE
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On 04/26/2023 at 12:30 PM Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Required Annual Inspection. Upon entry, LPA disclosed the purpose of the visit with staff. At approximately 1:00 PM, Administrator (ADM) Alberto Bernardino arrived.

During inspection, LPA inspected the physical plant inside and outside, the kitchen, and reviewed facility files.

1 Type B citation was issued (refer to LIC809-D for details). Additionally, Advisory Notes - Technical Violation (LIC9102) was issued for Licensee to replace the current Yard Sketch of the facility that accurately depicts the facility grounds and structures.

Additional visit will be required to complete annual inspection.

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
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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Document Has Been Signed on 04/26/2023 05:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: AGNES HOUSE
FACILITY NUMBER: 079201047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 of 2 gates, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Licensee shall add self-closing mechanism and fully functioning latch to both of the gates and send electronic pictures of them to LPA on or before due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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