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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200407
Report Date: 04/04/2025
Date Signed: 04/04/2025 01:19:01 PM

Document Has Been Signed on 04/04/2025 01:19 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:BERMUDA RESIDENTIAL CARE HOMEFACILITY NUMBER:
079200407
ADMINISTRATOR/
DIRECTOR:		CHARMAINE C. COLLADOFACILITY TYPE:
740
ADDRESS:984 BERMUDA DRIVETELEPHONE:
(925) 278-2914
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 6DATE:
04/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Charmaine C. Collado, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 04/04/25 at 09:10 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Administrator Charmaine C. Collado and explained the purpose of the visit.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 11/12/2024.

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Jill Clancy-Czuleger
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BERMUDA RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200407
VISIT DATE: 04/04/2025
NARRATIVE
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...Continued from 809

The following deficiency was observed during the visit:
Fence in yard has fallen over
The facility does not have a one week supply of nonperishable food
The facility does not have hospice care plan for R2
The facility has not been reporting incidents to CCLD
4 of 6 residents do not have admissions agreements in their file
3 of 6 residents do not have personal property and valuables list in their file
6 of 6 residents do not have a reappraisal document in their file
2 of 2 staff files checked did not have a health screening


The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Jill Clancy-Czuleger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 01:19 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 04/04/2025 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BERMUDA RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 by having a fence that has fallen over between the driveway and the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
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By POC date the Licensee agrees to submit a timeline of when the fence will be replaced. Additionally the Licensee agrees to send a photo of the repaired fence to CCLD.
Type A
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having an admissions agrement in 4 out of 6 resident files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
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The Licensee agrees put in signed resident agreements in to all resident files. Proof of Correction will be sent to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Jill Clancy-Czuleger
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 01:19 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 04/04/2025 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BERMUDA RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a health screening for 2 of 2 staff records that were reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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The licensee agrees to get a completed LIC 503 for any staff member that does not have one. Proof of Correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 by not having a one week supplies of nonperishable foods which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Licensee agrees to purchase a one week supply of nonperishable foods. Proof of correction will be sent to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Jill Clancy-Czuleger
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 01:19 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 04/04/2025 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BERMUDA RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a Personal Property, and Valuables list in 3 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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The Licensee agrees put in signed Personal Property, and Valuables list in to all resident files. Proof of Correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having an updated appraisal in 6 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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The Licensee agrees put in an updated apprasial needs and servies plan in to all resident files. Proof of Correction will be sent to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Jill Clancy-Czuleger
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 01:19 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 04/04/2025 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BERMUDA RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above by not having R2's hospice care plan at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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2
3
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The Licensee agrees have a completed hospice care plan in R2's file. Proof of Correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87211(a)(1)
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above by not submittig incident reports for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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2
3
4
The Licensee agrees to review the regulation and submitt a self certified letter of understanding. Proof of Correction will be sent to CCLD by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Jill Clancy-Czuleger
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025


LIC809 (FAS) - (06/04)
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