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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200418
Report Date: 09/13/2021
Date Signed: 09/13/2021 01:30:14 PM

Document Has Been Signed on 09/13/2021 01:30 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 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:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Shirley BordonTIME COMPLETED:
11:15 AM
NARRATIVE
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On 9/13/2021 at 9:40am, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Staff S1 and explained the purpose of the visit. Licensee Shirley Bordon arrived at approximately 10:17am.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and backyard. LPA observed COVID-19 signage posted in common areas. Common bathroom was equipped with soap, paper towels and garbage. Hand washing posters was posted in common bathroom. LPA observed food, PPE and paper supplies are sufficient. Common areas are disinfected daily.

During record review, LPA observed facility has a copy of Mitigation Plan on file.

LPA observed antifreeze and coolant in unlocked shed.

The following deficiency was observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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 09/13/2021 01:30 PM - It Cannot Be Edited


Created By: Allison O'Hollaren On 09/13/2021 at 10:55 AM
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 II
FACILITY NUMBER: 019200418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087(g) Buildings and Grounds
Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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. LPA observed antifreeze and coolant in unlocked shed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2021
Plan of Correction
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By POC date, Licensee agrees to lock all items that could pose a danger to clients in care and submit proof to CCL by fax or email.
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:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2021


LIC809 (FAS) - (06/04)
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