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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200991
Report Date: 07/10/2025
Date Signed: 07/16/2025 04:10:39 PM

Document Has Been Signed on 07/16/2025 04:10 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AGNES HOUSEFACILITY NUMBER:
079200991
ADMINISTRATOR/
DIRECTOR:		BERNARDINO, ALBERTOFACILITY TYPE:
740
ADDRESS:1644 BECKNER CTTELEPHONE:
(925) 338-2399
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 0DATE:
07/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Alberto Bernanrdino, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 07/10/25 at 9:00 AM, Licensing Program Analysts (LPAs) Andrew Christy and Jill Clancy-Czuleger arrived unannounced to conduct an annual required inspection. LPAs met with and spoke to administrator (ADM) Alberto Bernardino and explained the purpose of the visit. The facility’s fire clearance was approved for 5 Non Ambulatory and 1 Bedridden. LPAs observed that there are no reidents in care and confirmed this with Administrator. Administrator stated that they have never had a resident and were not planning on getting a resident in the near future but wanted to keep the license active. LPA's informed the administrator that the facility is not ready to retain a resident at this time. Administrator agrees that prior to admitting a resident the facility will call CCLD to conduct a walk thorough inspection to confirm that they are in compliance and up to licensing standards.

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms. All outdoor and indoor passageways are kept free of obstruction. LPAs observed a locked gate around the pool. A comfortable temperature is maintained at 77 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of potential future residents. The hot water temperature in the bathroom was measured at 131.5 degrees Fahrenheit. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Cabinets for centrally stored medication were locked, while sharps and chemicals were only locked some of the time. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last purchased on 04/25/2025. First aid kit was observed to be complete.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Andrew Christy
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AGNES HOUSE
FACILITY NUMBER: 079200991
VISIT DATE: 07/10/2025
NARRATIVE
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...Continued from LIC 809
The following deficiency was observed during annual visit:
  • At 10:00 AM, ADM stated that there are no staff records on site to be able to review. There was also no Emergency Disaster plan to review, and ADM promised to get it emailed so it can be printed for site.

The following observations were made but not cited on due to no residents in care:
  1. At 9:30 AM, LPAs observed multiple items of food not labeled with dates outside their original packaging, as well as expired items ranging to the year 2022.
  2. At 9:40, multiple cabinets meant for sharps and chemicals were observed to be unlocked, as well as many sharps being openly accessible in the kitchen.
  3. At 9:45 AM, LPAs observed fire exit blocked with trash cans and other various items. The designated bedridden room also had a table outside blocking the door.
  4. At 9:50 AM, LPAs noticed there were no posters with information regarding the state ombudsman, personal rights, and the complaint poster. As well, the license and administrator certificate were not on display.
  5. At 9:55 AM, the hot water temperature in the kitchen was measured to 131.5 degrees Fahrenheit
.

Due to a lack of residents in the facility, the deficiencies were not cited except staff records not being on site.

Exit interview conducted and a copy of this report was made available to the ADM.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Andrew Christy
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/16/2025 04:10 PM - It Cannot Be Edited


Created By: Andrew Christy On 07/10/2025 at 10:54 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: AGNES HOUSE
FACILITY NUMBER: 079200991

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there were no records on site to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee corrected this issue during the visit with a complete profile for the administrator.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Andrew Christy
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
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