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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200318
Report Date: 08/12/2022
Date Signed: 08/12/2022 03:14:52 PM

Document Has Been Signed on 08/12/2022 03:14 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 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:
08/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Angelica Chavez, CaregiverTIME COMPLETED:
03:25 PM
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On 8/12/2022 at 2:20PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Angelica Chavez, Caregiver and explained the purpose of the visit. Administrator, Shirley Borden, arrived at 2:35PM.

Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 signs were posted on the patio door that facility uses as main entrance. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 104.5 degrees Fahrenheit. Facility was doing laundry at the time of the inspection Fire extinguisher last serviced on 01/21/2021. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors log and temperature log for both clients and staff. LPA observed facility has a copy of the Infection Control Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BORDON HOME IV
FACILITY NUMBER: 019200318
VISIT DATE: 08/12/2022
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Continued from LIC809.

LPA requested the following documents to be submitted to CCLD by 8/19/2022.

LIC500 Personnel Report
LIC308 Designation of Administrative Responsibility
LIC610D Emergency Disaster Plan

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC809 (FAS) - (06/04)
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