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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200318
Report Date: 06/15/2023
Date Signed: 06/15/2023 05:11:02 PM

Document Has Been Signed on 06/15/2023 05:11 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:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shirley BordonTIME COMPLETED:
05:25 PM
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On this day at around 1:00 PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct annual required inspection. LPA was met by staff Angelica Chavez and explained the purpose of visit. Administrator Shirley Bordon arrived at a later time.

The facility is a Level 4i home vendorized by the Regional Center of the East Bay (RCEB). It has an approved fire clearance for 6 ambulatory clients.

LPA inspected the facility inside and out including but not limited to client 3 client bedrooms, 2 bathrooms, kitchen, dining and backyard. Facility was observed clean and with sufficient lighting. There was no body of water observed. Hot water measured at 109.6 F in one of the bathrooms. There was sufficient supply of perishable and non perishable foods observed. Fire extinguisher in the kitchen was observed full that was last inspected on 2/9/2023. Carbon monoxide and smoke detector were tested and observed functional.

Facility has an approved mitigation plan. First aid kit was observed complete. Last fire drill was done in March 2023.

At 1:15 PM, LPA reviewed Medication Administration Record (MAR) and medications for all 4 clients. At 1:45 PM, LPA reviewed P & I money and log. At 2 PM, LPA reviewed 3 client files, Administrator and 2 staff files.

Type A deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Administrator. A copy of this report and Appeal Rights were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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 06/15/2023 05:11 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/15/2023 at 04:52 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 HOME IV
FACILITY NUMBER: 019200318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)


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 unlocked medications in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2023
Plan of Correction
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Administrator locked medicines during inspection. Deficiency is cleared.
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: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
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