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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201555
Report Date: 07/01/2025
Date Signed: 07/01/2025 01:08:21 PM

Document Has Been Signed on 07/01/2025 01:08 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:GABRIEL'S HOUSE 2FACILITY NUMBER:
079201555
ADMINISTRATOR/
DIRECTOR:		BERNARDINO, JANE PABUSTANFACILITY TYPE:
740
ADDRESS:1569 MENDOCINO DRIVETELEPHONE:
(925) 470-7160
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 0DATE:
07/01/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Jane Bernardino, Licensee/ApplicantTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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On 7/1/2025 at 9:50AM, Licensing Program Analysts (LPAs) G. Luk and A. Christy conducted a Pre-licensing Inspection as a result of a change of location. LPAs met with Licensee/Applicant, Jane Bernardino.

LPAs toured facility including but not limited to resident's bedrooms, bathrooms, living room, dining area, kitchen, garage, and outdoor area. LPAs observed lighting in all rooms. Hot water was measured at 106.6 degrees F in the hallway bathroom. Facility bathrooms have grab bars and non-skid mat/materials for the showers. LPAs observed facility have some non-perishable and perishable food supplies available. Licensee will purchase additional foods prior to residents moving into facility. Carbon monoxide and smoke detectors are in operating conditions. First aid kit was complete.

Licensee will bring all 6 resident's furniture including bed, chair, night stand, lamp, and dresser from the other facility once the facility is licensed. Licensee will transfer the telephone land line to this facility when the facility is licensed in order to the same telephone number.


The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. LPAs observed facility had fire extinguishers that were observed to be full. However, they were not serviced or have purchase receipts available.

2. LPAs observed the facility sketch for the garage did not include the storage room in the garage. Licensee will update the facility sketch.

(Continue on LIC809C...)

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Grace Luk
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
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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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GABRIEL'S HOUSE 2
FACILITY NUMBER: 079201555
VISIT DATE: 07/01/2025
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3. LPAs observed licensee did not have a bedridden plan of operations. Licensee will also need to update the LIC610E regarding evacuation of residents who are bedridden.

4. LPAs observed facility does not have the theft and investigation policy and procedures posted.

5. LPAs observed facility did not have the fire safety plan posted.

Licensee/Applicant will submit proof of corrections to CCLD on/before 7/14/2025.


Exit interview conducted with Jane and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Grace Luk
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
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