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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200407
Report Date: 08/28/2025
Date Signed: 08/28/2025 11:05:23 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250403131419
FACILITY NAME:BERMUDA RESIDENTIAL CARE HOMEFACILITY NUMBER:
079200407
ADMINISTRATOR:CHARMAINE C. COLLADOFACILITY TYPE:
740
ADDRESS:984 BERMUDA DRIVETELEPHONE:
(925) 278-2914
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 6DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Natasha Reyes, StaffTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff did not notify resident's responsible party of change in condition.
INVESTIGATION FINDINGS:
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On 9/28/2025 at 10:30AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver the findings for the above allegations. LPA explained the purpose of the visit with Staff Natasha Reyes. Administrator Charmaine C was called and informed of the visit. Collado. During the course of the investigation, LPA J. Clancy-Czuleger interviewed the administrator and residents, and reviewed records.

On the allegation:Staff did not notify the residents responsible party of change in condition. RP stated that they were only informed of stage 3-4 wounds from hospice and were never informed by anyone at the home. When asked S1 stated that from what they understood, hospice was in charge of all aspects of wound care and thought that included notifying the resident’s responsible party.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The California Code of Regulations, Title 22 has been cited. Exit interview conducted. A copy appeal rights, and this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250403131419

FACILITY NAME:BERMUDA RESIDENTIAL CARE HOMEFACILITY NUMBER:
079200407
ADMINISTRATOR:CHARMAINE C. COLLADOFACILITY TYPE:
740
ADDRESS:984 BERMUDA DRIVETELEPHONE:
(925) 278-2914
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 6DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Natasha Reyes, Staff TIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Neglect/ Lack of supervision resulting in resident developing pressure injury while in care
Staff did not ensure resident's hygiene needs are being met
Staff do not ensure that resident has clean bedding
INVESTIGATION FINDINGS:
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On 9/28/2025 at 10:30 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver the findings for the above allegations. LPA explained the purpose of the visit with Staff Natasha Reyes. Administrator Charmaine C was called and informed of the visit.

During the course of the investigation, LPA J. Clancy-Czuleger interviewed the staff and residents, and reviewed records.

On the allegation: Neglect/ Lack of supervision resulting in resident developing pressure injury while in care. R1 was on hospice. Staff stated that once they noticed that R1 was developing skin irritation they notified R1’s hospice agency and that they waited for a hospice agency visit but they did not come. S1 stated that they made multiple attempts to contact the hospice agency, but the hospice did not come. S1 explained that they are not allowed to provide wound care and rely on hospice to care for wounds.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20250403131419
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/28/2025
NARRATIVE
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Continued from LIC9099A...

On the allegation:

Staff did not ensure resident's hygiene needs are being met. Based on interviews staff were offering showers to R1 but R1 would deny a shower. S1 stated that staff would offer to bring R1 to the shower but R1 would refuse, and staff would then offer bed baths which R1 would sometimes accept and sometimes deny. S1 said they did what they could, but they were not going to force R1 to shower/bath as it was R1’s personal right to deny.



On the allegation:

Staff do not ensure that residents have clean bedding. Based on interviews the facility has stained pillows. S1 stated that the bedding will sometimes discolor over time and after use. S1 stated that they reuse pillows, but they will clean and sanitize between different residents. S1 said that if a pillow or other bedding is too dirty or destroyed, they will toss it and replace it with new bedding but will do what they can to clean an item before making that decision.



Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20250403131419
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2025
Section Cited
CCR
87468.1(a)(8)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
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The facility agrees to review the regulation and create a plan of communication for informing families of residents change of condition and submit it to CCLD by POC date.
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This requirement was not met as evidenced by:
Based on interviews and observations the facility did not communicate R1's change of condition with family
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4