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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600608
Report Date: 01/09/2025
Date Signed: 01/23/2025 03:00:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2024 and conducted by Evaluator Patricia Manalo
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241106162604
FACILITY NAME:BORDON HOMESFACILITY NUMBER:
015600608
ADMINISTRATOR:BORDON, SHIRLEYFACILITY TYPE:
735
ADDRESS:4505 DARCELLE DRIVETELEPHONE:
(510) 487-3627
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 3DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Shirley Bordon, Administrator TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Insufficient staff based on the Client’s needs and services
Gastrostomy care not provided by professionally trained staff

INVESTIGATION FINDINGS:
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On this day at around 2:35 PM, LPAs L. Fontanilla and P. Manalo arrived at the facility to deliver findings for the above allegations.

On 11/12/2024, LPAs L. Fontanilla and P. Manalo conducted interviews and obtained records such as IPPs, Physician’s Reports, Lic. 500.

Insufficient staff based on the Client’s needs and services

A review of the facility’s Lic 500 dated 11/6/2024 indicates the following: 1st shift is split from 7am-12pm then 2pm-6pm; 2nd shift is split from 10am-3pm then 6pm-10pm.
From 12pm till 2pm and 6pm till 10pm, there is only one staff on shift. From 10pm till the next day at 9:59 am, there is no staff on shift.
Continue LIC9099-C... *This is an amended copy of report previously issued on 01/09/2025.*
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20241106162604
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BORDON HOMES
FACILITY NUMBER: 015600608
VISIT DATE: 01/09/2025
NARRATIVE
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Continue from LIC9099...

The facility is a Level 4H home and has a client who is total care and depends on others for all ADLs, has catheter, on tube feeding, needed hoyer lift for transfers and needed to be repositioned every two hours.

Gastrostomy care not provided by professionally trained staff

During the course of investigation, LPAs interviewed staff and reviewed records. Based on proof of staff training provided to LPAs, 5 staff were trained by a registered nurse (RN) on 9/9/2024. Administrator states the RN who conducted the training is not affiliated with any home health agency.

During interviews conducted with staff, S9 denied providing care to C1 because of lack of training in gastrostomy care. S7 states that S7 received training from S8 and S10. S7 had only had shadow training hours for C1's care.

LPAs reviewed proof of training provided. The proof of training does not indicate the topics discussed and the date it was signed by the nurse. LPAs observed that S9 name was added manually to the list with a 9-9-24 date written next to S9 name.

Based on interviews and record reviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22 are being cited on the attached LIC 9099D.

Exit interview was conducted with Licensee and Appeal Rights was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2024 and conducted by Evaluator Patricia Manalo
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241106162604

FACILITY NAME:BORDON HOMESFACILITY NUMBER:
015600608
ADMINISTRATOR:BORDON, SHIRLEYFACILITY TYPE:
735
ADDRESS:4505 DARCELLE DRIVETELEPHONE:
(510) 487-3627
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 3DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Shirley Bordon, Administrator TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Administrator is not on the facility premises a sufficient number of hours
INVESTIGATION FINDINGS:
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On this day at around 2:35 PM, LPAs L. Fontanilla and P. Manalo arrived at the facility to deliver findings for the above allegations.

During the course of investigation, LPAs interviewed staff and reviewed records. Based on interviews conducted with some staff, the Licensee does come to the facility to drop off groceries or accompany a client to the doctor for appointments, if needed. And that the Administrator does come to the facility regularly.

However, other staff interviewed state the Administrator comes to the facility one ot two hours a week. Staff were unable to tell LPA the required hours an Administrator needs to be present at the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20241106162604
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BORDON HOMES
FACILITY NUMBER: 015600608
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2025
Section Cited
CCR
80092.1(n)
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General Requirements for Restricted Health Conditions 80092.1(n)The licensee shall ensure that the client’s health-related service needs are met and shall follow the approved plan for each client.
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The licensee states that they will hire an extra night shift person. Pending the hiring, the licensee is going to assign staff to assist the client at night.
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This requirement is not met as evidenced by: Based on record review conducted, C1 depends on others for all activities of daily living (total care), has G tube and catheter, is incontinent and needs hoyer lift for transfer. C1 needs to be repositioned every two hours as indicated in the plan of care. Facility records show from 10pm until 9:59 am the following day, there is no staff designated to assist C1. C1 starts to get assistance from staff at 10am which poses an immediate health and safety risk to the health and safety of C1 and other clients in care.
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Type B
01/23/2025
Section Cited
CCR
80092.1(f)(2)
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 80092.1(f)(2)General Requirements for Restricted Health Conditions(f) Prior to admission of a client ...(2) Ensure that facility staff who will participate in meeting the client's specialized care needs complete training provided by a licensed professional sufficient to meet those need
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The licensee will send proof of training to CCLD by POC date.
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This requirement is not met as evidenced by: Based on staff interview and record review, proof of training on gastrostomy provided did not indicate the date when the training occurred
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5