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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 11:07:37 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:May Angelica IgnacioTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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On this day at around 9:45 am, LPA L. Fontanilla arrived unannounced to conduct a case management visit to issue deficiencies in connection with additional information obtained during investigation of complaint #15-AS-20241106143700. LPA met with Ignacio and explained the purpose of the visit. The Licensee was out for an appointment but was informed about the visit over the phone.

During the course of investigation, LPA conducted reviews and record reviews. The following deficiency was observed:

C4’s last visit to the dentist was done in 2013 and has not had any follow up visits since then.

Exit interview was conducted with Ignacio who was authorized by Shirley to sign the report. 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
80072(9)

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80072(9) Personal Rights
(9) To receive or reject medical care, or health-related services, except for minors and other clients for whom a guardian, conservator, or other legal authority has been appointed.
This requirement is not met as
evidenced by: Based on record review conducted, C4's last visit with the dentist was done in 2013 and has not had any follow up visit since then which poses a potential risk to the health and safety of clients under care.
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Licensee will make sure that a dental appointment with C4 will be made as soon as possible and will provide LPA information 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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