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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701205
Report Date: 06/28/2024
Date Signed: 06/28/2024 10:47:22 AM

Document Has Been Signed on 06/28/2024 10:47 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BERNIE'S CARE HOME SERVICES LLCFACILITY NUMBER:
392701205
ADMINISTRATOR/
DIRECTOR:		VARGAS, BERNADETTE P.FACILITY TYPE:
740
ADDRESS:936 ROYAL OAKS DRIVETELEPHONE:
(209) 373-8399
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 4DATE:
06/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:VARGAS, BERNADETTE TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management visit following up on an email that was sent to LPA Lewis regarding a hospice waiver increase . LPA explained purpose of visit to the licensee.

The facility was given a hospice increase on 06/09/2023 and 03/28/2024. The current hospice waiver is for four (4) residents.

The facility has three (3) staff currently and has access to (3) additional staff that or on call if needed.

LPA Lewis reviewed staff and resident files. LPA Lewis conducted a facility tour and observation. LPA conducted facility tour with licensee. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed to contain no foul odors. Fire extinguisher was full charged and dated 08-14-23. Room temperature was 76*F. Smoke alarms and carbon detectors are functioning properly.

Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
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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