<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200418
Report Date: 09/06/2024
Date Signed: 09/06/2024 02:20:24 PM

Document Has Been Signed on 09/06/2024 02:20 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/
DIRECTOR:		BORDON, SHIRLEY E.FACILITY TYPE:
735
ADDRESS:5659 DON COURTTELEPHONE:
(510) 668-0103
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 3DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Shirley/Tony BordonTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day at around 11 am, Licensing Program Analysts (LPAs) Luisa Fontanilla and Patricia Manalo arrived unannounced to conduct an annual required inspection. LPAs met with Administrator Shirley and Tony Bordon. LPAs explained to the Administrator the purpose of the visit.

During the visit, LPAs inspected the facility inside and out including but not limited to resident bedrooms, kitchen, dining area, living area, garage and backyard. Hot water in the bathroom faucet measured at 109.8 Fahrenheit. There was sufficient supply of perishable and non perishable foods. A fire extinguisher that appeared full and was last serviced 09/06/2024 was observed in the kitchen. Carbon monoxide and smoke detectors were tested and observed operational. No bodies of water were observed. Hallways and passageways were observed free of obstruction. The facility has ample supply of towels, sheets and warm blankets. Fire drill was conducted on 06/17/2024. First Aid Kit is complete.

At around 12:30 P.M, LPAs reviewed 3 resident files and 4 staff files. At around 1:00 pm, LPAs reviewed medications and Medication Administration Record (MAR). At 1:30 pm, LPAs reviewed 3 P&I money and log. The facility has surety bond sufficient to cover the amount of cash being handled at one time.

Cont. LIC809c....
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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 II
FACILITY NUMBER: 019200418
VISIT DATE: 09/06/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
... Cont.

LPAS requested the following documents to be submitted to CCL by September 13, 2024:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report/ Client Roster
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance
  • Surety Bond
  • Current Administrator’s Certificate
  • LIC 400 Affidavit of Cash Resources
  • Driver's License of S2 and S3

No deficiencies found on this visit. Exit interview was conducted with Tony Bordon.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4