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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200991
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:38:04 PM

Document Has Been Signed on 03/30/2022 02:38 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:
03/30/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Alberto BernandinoTIME COMPLETED:
03:30 PM
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On 03/30/2022 at 10:00AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with Administrator (ADM) Alberto Bernandino. LPA observed 1 staff wearing face mask during visit. LPA observed no residents living at the facility.

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. The ADM is the designated infection control leader. LPA observed COVID-19 signage in common areas. Facility has a completed mitigation plan in place dated 01/24/21 to mitigate the spread of COVID-19. LPA inspected the facility inside and outside. 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. He had evidence of Liability Insurance.

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 a comfortable temperature. The hot water was within the acceptable range of 105 to 120 degrees. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational. Sharp objects were in a locked drawer.

Updated copies of the following documents were requested for facility file and are to be emailed to LPA by 04/06/2022:
  • LIC500- Personnel Report
  • LIC610E- Emergency/Disaster Plan

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to ADM.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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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