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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201047
Report Date: 02/10/2023
Date Signed: 02/10/2023 06:57:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/08/2023 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230208084824
FACILITY NAME:AGNES HOUSEFACILITY NUMBER:
079201047
ADMINISTRATOR:BERNARDINO, ALBERTOFACILITY TYPE:
740
ADDRESS:1660 ARKELL RDTELEPHONE:
(925) 482-0601
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Gladys EnriquezTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Facility staff did not follow COVID-19 protocols.
INVESTIGATION FINDINGS:
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On 02/10/2023, Licensing Program Analyst (LPA) J. Sampair arrived unannounced at 2:43PM to conduct a complaint investigation of the allegation above. The LPA met with Gladys Enriquez.

During the investigation, the LPA conducted interviews of 3 staff members and 2 witnesses.

Based on the interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED.

Two (2) citations were issued (refer to LIC 9099D).

Exit interview conducted and copy of this report provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20230208084824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 079201047
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Administrator shall: (1) obtain all supplies necessary for adhering to the current COVID-19 protocols AND (2) training all staff members in all aspects of those COVID-19 protocols in accordance with PIN 23-02-ASC.
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Based on interviews, the licencee did not comply with the section cited above, which poses a potential Health, Safety or Personal Rights risk to residents in care.
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Type B
02/17/2023
Section Cited
CCR
87211(a)(2)
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87211 REPORTING REQUIREMENTS
(a) Each licensee shall furnish reports as the Department may require ... (2) Occurrences, such as epidemic outbreaks which threaten ... health of residents ... within 24 hours

This requirement is not met as evidenced by:
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Administrator shall complete and send copy of LIC624 to the Oakland Regional Office by fax or email.
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Based on interviews, the licencee did not comply with the section cited above, which poses a potential Health, Safety or Personal Rights risk to residents in care.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2