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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600608
Report Date: 12/27/2023
Date Signed: 12/27/2023 01:34:33 PM

Document Has Been Signed on 12/27/2023 01:34 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 4DATE:
12/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH: Estela Moscoso TIME COMPLETED:
01:50 PM
NARRATIVE
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On this day at around 10:05 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA met with staff Estela Moscoso and informed about the purpose of the visit. Administrator Shirley Bordon was informed over the telephone and she authorized Moscoso to sign the report.

During the visit, LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, kitchen, dining, garage and backyard. Hot water in the kitchen measured at 115 degrees Fahrenheit. There were no bodies of water observed. There was sufficient supply of perishable and non perishable foods. Three clients were observed at the facility. One client is currently out staying with family.
Medications were observed locked in a cabinet next to the kitchen. Fire extinguisher in the kitchen appeared full and was last serviced on 2/9/2023. Smoke detectors and carbon monoxide were tested and observed functional.

At 10:50 am, LPA with Moscoso reviewed P&I money and log. At 12:15pm, LPA reviewed 4 client files and 3 staff files. At 12:53pm, LPA reviewed medication and Medication Administration Record (MAR).

Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023
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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Document Has Been Signed on 12/27/2023 01:34 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/27/2023 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BORDON HOMES
FACILITY NUMBER: 015600608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in installing sliding bolt in exit door which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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By POC date, Administrator will replace sliding bolt with a self closing latch and send photo proof to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/27/2023 01:34 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/27/2023 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BORDON HOMES
FACILITY NUMBER: 015600608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having 1) skylight leaking 2) broken refrigerator lid/rusted fridge door 3) not enough lighting 4) trelis with missing wood, protruding nail which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Administrator will fix items 1-4 and submit proof to CCL by POC date.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having a shaded area for outdoor activity which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
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Administrator will install shaded area for outdoor activities and send photo proof to CCL.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023


LIC809 (FAS) - (06/04)
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