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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200813
Report Date: 05/08/2022
Date Signed: 05/08/2022 10:13:53 AM

Document Has Been Signed on 05/08/2022 10:13 AM - 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:GABRIEL'S HOUSE 1FACILITY NUMBER:
079200813
ADMINISTRATOR:BERNARDINO, JANE PABUSTANFACILITY TYPE:
740
ADDRESS:3109 CONCORD BLVDTELEPHONE:
(925) 470-7160
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY: 6CENSUS: 5DATE:
05/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Albert Bernardino, Administrator TIME COMPLETED:
10:25 AM
NARRATIVE
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On 05/08/2022 at 9:15 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with staff Belle Ampero. Administrator Albert Bernardino arrived and joined later.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2022
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 2
Document Has Been Signed on 05/08/2022 10:13 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 05/08/2022 at 09:32 AM
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: GABRIEL'S HOUSE 1
FACILITY NUMBER: 079200813

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2022
Section Cited
CCR
87507(c)

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Admission agreements shall be signed and dated, ... no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
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Licensee shall arrange a meeting with R1 and/or R1's representative to complete all pages of an Admissions Agreement.

Licensee shall submit copy of completed Admissions Agreement, dated and signed licensee, resident and/or resident's representative, to CCLD by POC date 5/30/22
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Based on observation and interview, licensee failed to ensure that a completed Admissions Agreement is placed in the record file of R1.
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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 Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2022


LIC809 (FAS) - (06/04)
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