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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200318
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:35:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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 Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241106143700
FACILITY NAME:BORDON HOME IVFACILITY NUMBER:
019200318
ADMINISTRATOR:SHIRLEY E. BORDONFACILITY TYPE:
735
ADDRESS:4273 DUCHESS COURTTELEPHONE:
(510) 471-3174
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 4DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Shirley BordonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Insufficient staff based on the Client’s needs and services.
Staff mismanaged Clients’ medication.
INVESTIGATION FINDINGS:
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On this day at around 2:25pm, LPA Luisa Fontanilla arrived unannounced to deliver finding for the above allegation and met with Shirley Bordon. LPAs explained to Bordon the purpose of the visit.

During the course of investigation, LPAs conducted interviews and record reviews.

1. Insufficient staff based on the Client’s needs and services.
Based on interviews conducted, there are clients who wake up 3-4x at night, walk around looking for food, play the piano, cry and do other things. One client was observed taking a shower and drinking water from the shower at around 2am.
continuation on Lic 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 3
Control Number 15-AS-20241106143700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BORDON HOME IV
FACILITY NUMBER: 019200318
VISIT DATE: 02/20/2025
NARRATIVE
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Based on record reviews and interviews conducted, the facility does not have an awake staff to supervise clients.

2. Staff mismanaged Clients’ medication.



Based on interviews conducted with staff, one staff denied giving extra Melatonin to the clients. However, other staff interviewed state there are clients who are given extra Melatonin.

During the visit conducted on 11/12/2024, LPAs observed a bottle of Melatonin in the medicine cabinet. The bottle did not have a label. The presence of the extra bottle of Melatonin in the medicine cabinet confirmed the information provided by RP to CCL.

Based on observation and interviews conducted, the above allegations are substantiated.

Based on LPAs observations and interviews 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.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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 Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241106143700

FACILITY NAME:BORDON HOME IVFACILITY NUMBER:
019200318
ADMINISTRATOR:SHIRLEY E. BORDONFACILITY TYPE:
735
ADDRESS:4273 DUCHESS COURTTELEPHONE:
(510) 471-3174
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 4DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Shirley BordonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator is not on the facility premises a sufficient number of hours.
INVESTIGATION FINDINGS:
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13
On this day, LPA L. Fontanilla arrived unannounced to deliver finding for the above allegation and met with Shirley Bordon. LPA explained to Bordon the purpose of the visit.

During the course of investigation, LPA conducted interviews and record reviews.

Based on interviews conducted with staff, the Licensee/Administrator comes to the facility to drop off groceries throughout the week. The Administrator also accompanies clients for doctors’ appointment, if needed. However, there were staff interviewed who state that the Administrator comes and stays at the facility 1-2 hours a week only.

Based on interviews and record reviews conducted, the above allegation is unsubstantiated. 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.

There is no deficiency noted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 3