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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200991
Report Date: 12/08/2022
Date Signed: 12/08/2022 02:30:23 PM

Document Has Been Signed on 12/08/2022 02:30 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
E BAY DELTA AC/SC, 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:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Alberto Bernardino, AdministratorTIME COMPLETED:
02:40 PM
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On 12/08/2022 at 1:25 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Administrator, Alberto Bernardino and explained the purpose of the visit. Facility currently does not have any residents or Staff. Administrator and their family currently lives in the home.

During the Infection Control Inspection, LPA toured facility with Alberto and 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 and nearby facility. Facility recently removed their screening station from the front entrance but still obtains hand sanitizer and others supplies ready for use. Facility has a sufficient two day perishable and one week non-perishable food supply. Common touched surfaces are disinfected at least once daily.

Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility has a mitigation plan. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. Fire extinguisher was observed serviced. LPA observed facility passages inside and out free of obstruction.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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