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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701205
Report Date: 10/24/2022
Date Signed: 10/24/2022 02:26:04 PM

Document Has Been Signed on 10/24/2022 02:26 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:BERNIE'S CARE HOME SERVICES LLCFACILITY NUMBER:
392701205
ADMINISTRATOR:VARGAS, BERNADETTE P.FACILITY TYPE:
740
ADDRESS:936 ROYAL OAKS DRIVETELEPHONE:
(209) 373-8399
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 0DATE:
10/24/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Bernardette Vargas, AdministratorTIME COMPLETED:
02:20 PM
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Component II completion: Unsuccessful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Bernardette Vargas, Administrator
Interview Method: Telephone interview


On October 24, 2022, Administrator participated in COMP II. Identification of the Administrator was verified through interview questions based on photo ID and other identifying personal information. Administrator did not provide sufficient knowledge the program and the California Code Title 22 Regulations. Component II will be rescheduled once LIC 809 is signed and return back to CAB.

Exit interview conducted with Administrator. PDF copy sent via email to Administrator.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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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