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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701205
Report Date: 11/01/2022
Date Signed: 11/01/2022 10:49:08 AM

Document Has Been Signed on 11/01/2022 10:49 AM - 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:
11/01/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Bernadette Vargas, Applicant/AdministratorTIME COMPLETED:
10:40 AM
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Component II completion: Successful

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

On November 1, 2022, Applicant/Administrator participated in COMP II. Identification of the Applicant/ Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant/Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements/CPMB associations & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant/Administrator. Report sent via email PDF and informed to return back to CAB signed by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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