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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200418
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:31:00 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-20241106160249
FACILITY NAME:BORDON HOME IIFACILITY NUMBER:
019200418
ADMINISTRATOR:BORDON, SHIRLEY E.FACILITY TYPE:
735
ADDRESS:5659 DON COURTTELEPHONE:
(510) 668-0103
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 3DATE:
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.
INVESTIGATION FINDINGS:
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On 2/20/2025 at around 12:25 pm, Licensing Program Analyst (LPA) L. Fontanilla arrived unannounced to deliver finding of the above allegation. LPA met with staff May Angelica Ignacio and explained the purpose of the visit. LIcensee/Administrator Shirley Bordon was informed about the visit.

During the course of the investigation, the department obtained and reviewed the following documents: LIC 500, IPPs, DSP training for all staff, and Physician’s Reports and conducted interviews.

Allegation: Insufficient staff based on the Client’s needs and services

LPAs interviewed staff and reviewed records. All interviews and record reviews conducted indicate that there is no night shift. One client has seizure and had at least 2 episodes that occurred around 1am-2am in the bathroom. 2 of the 3 clients wake up at night, walk around and would look for food and eat. 2 of 3 clients are incontinent.

Based on the Lic 500 submitted to CCL, there is no awake staff assigned from 10 pm till 6am to supervise clients or change diapers of incontinent clients.

Based on interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be Substantiated. CCR Title 22 is cited on the attached LIC9099D.
Exit interview was conducted and Appeal Rights was provided.

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-20241106160249
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 II
FACILITY NUMBER: 019200418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2025
Section Cited
CCR
80078(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.
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By POC date, the Administrator will designate an awake staff and submit Lic 500 to CCL.
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This requirement is not met as evidenced by: Based on interviews and record reviews conducted, the facility doe snot have an awake staff to change diapers of incontinent client/supervise clients who wake up at night which poses a potential risk to the health and safety of clients under care.
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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.
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 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-20241106160249

FACILITY NAME:BORDON HOME IIFACILITY NUMBER:
019200418
ADMINISTRATOR:BORDON, SHIRLEY E.FACILITY TYPE:
735
ADDRESS:5659 DON COURTTELEPHONE:
(510) 668-0103
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 3DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Shirley BordonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Administrator is not on the facility premises a sufficient number of hours.
INVESTIGATION FINDINGS:
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On this day at around 12:25 pm, LPA L. Fontanilla arrived unannounced to dleiver finding for the above allegation and met with staff Angelica May Ignacio. LPA explained to Ignacio the purpose of the visit. Licensee/Administrator was informed about the visit.
During the course of the investigation, LPAs interviewed staff and reviewed records.

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