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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200991
Report Date: 06/16/2021
Date Signed: 06/16/2021 04:02:52 PM

Document Has Been Signed on 06/16/2021 04:02 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:
079200991
ADMINISTRATOR:BERNARDINO, ALBERTOFACILITY TYPE:
740
ADDRESS:1644 BECKNER CTTELEPHONE:
(925) 338-2399
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 0DATE:
06/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Alberto Bernardino, AdministratorTIME COMPLETED:
04:15 PM
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On 06/16/21 at 2:30 PM, Licensing Program Analyst (LPA) conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 1 staff wearing face mask during visit. LPA observed no residents living at the facility. Administrator stated they wanted to keep the license and has continued to pay the annual fees on time.

LPA observed one central entry point designated for universal entry screening at the main entrance. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Per staff, the designated infection control leader is the administrator. LPA observed COVID-19 signages in common areas. Facility has a completed mitigation plan in place dated 01/24/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with staff as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. Administrator is the designated infection control leader. LPA observed locked medication cabinets in the kitchen and locked toxic chemical cabinets located inside the laundry area. Adequate PPE supplies were observed stored in the garage. All staff have been fully vaccinated since January 2021.

Continued on next page LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2021
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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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: 079200991
VISIT DATE: 06/16/2021
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There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 72 degrees Fahrenheit. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational. A written Emergency/Disaster plan dated 06/06/20 was observed posted in the kitchen area. Sharp objects were locked underneath the kitchen sink.

Updated copies of the following documents were requested for facility file and are to be emailed to LPA by 06/16/21:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC809 (FAS) - (06/04)
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