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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200318
Report Date: 03/13/2025
Date Signed: 03/13/2025 11:07:14 AM

Document Has Been Signed on 03/13/2025 11:07 AM - 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/
DIRECTOR:		SHIRLEY E. BORDONFACILITY TYPE:
735
ADDRESS:4273 DUCHESS COURTTELEPHONE:
(510) 471-3174
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
03/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Shirley Bordon/May Angelica IgnacioTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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On this day at around 9:45 am, LPA Luisa Fontanilla arrived unannounced to conduct a case management visit to issue deficiencies in connection with complaint #15-AS-20241106143700. LPA met with May Angelica Ignacio and explained the purpose of the visit. Licensee was out of the facility for an appointment but informed about the purpose of the visit over the phone.

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

Deficiencies were observed and can be found in the attached Lic 809D.

Exit interview was conducted with May Angelica Ignacio who was authorized by Shirley to sign the report and Appeal Rights was provided.

Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Luisa FontanillaTELEPHONE: (510) 286-7147
DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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 03/13/2025 11:07 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2025
Section Cited
CCR
80087(a)

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80078(a) Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
Based on interviews conducted, there are clients who wake up at night, wander around the facility, take a shower and drink water from the shower but no awake staff to supervise which poses a potential health and safety risk to the clients under care.
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Licensee states a night shift staff will be assigned to supervise clients who wake up at night. A copy of Lic 500 will be provided.
Type B
03/20/2025
Section Cited
CCR
80075(B)(3)

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80075(B)(3) Health Related Services
(b) Clients shall be assisted as needed with self-administration...
(3) Assistance with self-administration does not include forcing a client to take medications, hiding or camouflaging medications in other substances without the client's knowledge and consent...
This requirement is not met as evidenced by:
Based on interviews conducted, staff gives clients extra dose of melatonin without doctor’s order and without client’s consent which poses a potential risk to the health and safety of clients under care.




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Licensee will 1) retrain staff on section cited and 2) obtain doctor order if additional dose of melatonin is needed for the clients; will submit proofs to CCL by POC date.

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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.
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Luisa FontanillaTELEPHONE: (510) 286-7147

DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025

LIC809 (FAS) - (06/04)
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