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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804162
Report Date: 11/06/2023
Date Signed: 11/06/2023 06:32:39 PM

Document Has Been Signed on 11/06/2023 06:32 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PACIFIC GARDENS ON HAWKESBURYFACILITY NUMBER:
486804162
ADMINISTRATOR:BERNARDINO, KRISTINEFACILITY TYPE:
740
ADDRESS:120 HAWKESBURY WAYTELEPHONE:
(760) 296-7562
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
11/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Kristine BernardinoTIME COMPLETED:
04:37 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Pre-Licensing Inspection and met with care staff, Myla Grace Alcalde. Applicant/Administrator, Kristine Bernardino arrived a few minutes later.

Applicant has applied for a Change of Ownership at this location and currently has 6 residents in care. LPA started the Prelicensing visit on 10/27/2023 and observed the following on that date and during todays continuation of the Prelicensing inspection. Facility is a one story residence with four resident bedrooms, 3 bathrooms, living room, dining room, kitchen area, and the garage. All resident rooms have the required furnishings, and now include a lamp in resident bedrooms. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in tested bathrooms read at 115, 117 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. The refrigerator was observed to be clean and there was plenty of perishable and Non perishable foods that appeared in good condition and stored properly. Cleaning supplies are locked under kitchen sink, but during todays inspection LPA found a small bottle of Lysol along with a hand held razor, bottle of super glue, neosporin, can spray that contains lidocaine, all accessible in master bedroom bathroom. Facility explained the items belong to staff S1. LPA went over items being accessible to residents and once again explained the master bedroom bathroom may only be used by the two residents who occupy that bedroom, R1 and R2. LPA requested removal of all accessible toxins and items belonging to staff S1, that should not be stored in the residents bedroom. Personnel records and resident records are stored in locked cabinet. Medication is centrally stored and locked.

Facility received an approved fire clearance dated August 8, 2023 that allows for 6 non-ambulatory residents and there is no approval for bedridden as the facility recently removed the fire sprinklers with approval from the fire department.
Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PACIFIC GARDENS ON HAWKESBURY
FACILITY NUMBER: 486804162
VISIT DATE: 11/06/2023
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 Fire Extinguishers were last serviced May 25, 2023. There are working smoke detectors and carbon monoxide detector. Required postings were observed, including a copy of the Admission Agreement. Auditory alarms on doors were operational.

Applicant to submit copy of Liability Insurance to Centralized Applications Bureau Analyst

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. Component III was conducted today, with Applicant, Kristine Bernardino. Pre-Licensing is complete, with no deficiencies. LPA will notify Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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