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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201336
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:32:07 PM

Unsubstantiated


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-20241106153558
FACILITY NAME:BORDON HOME IIIFACILITY NUMBER:
019201336
ADMINISTRATOR:BORDON, SHIRLEYFACILITY TYPE:
735
ADDRESS:4585 DARCELLE DRIVETELEPHONE:
(510) 431-3272
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:4CENSUS: 3DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Shirley BordonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Administrator is not on the facility premises a sufficient number of hours.
Insufficient staff based on the Client’s needs and services.
INVESTIGATION FINDINGS:
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On this day at around 1:25pm, LPA L. Fontanilla arrived at the facility to deliver finding for the above allegation and met with Administrator Shirley Bordon. LPA explained to Bordon the purpose of the visit.

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

Allegation: Administrator is not on the facility premises a sufficient number of hours.

During the course of investigation, LPAs interviewed staff and reviewed records. Based on interviews conducted with staff, the Licensee does come to the facility to drop off groceries or accompany a client to the doctor for appointments, if needed. And that the Administrator does come to the facility regularly. However, other staff interviewed state the Administrator comes to the facility one to two hours in a week.
continuation on Lic 9099C
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: 1 of 2
Control Number 15-AS-20241106153558
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 III
FACILITY NUMBER: 019201336
VISIT DATE: 02/20/2025
NARRATIVE
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Allegation: Insufficient staff based on the Client’s needs and services.

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

Based on interviews conducted with staff, there is no client that needs 1:1 supervision. In case a client gets up at night, a staff member would get up to assist. 1 of 3 clients is independent. One client gets up to use the bathroom but would go back to bed. None of the clients stay up at night.

Based on LPA observation and record reviews conducted, there is one client who would benefit from a 1:1. The client gets isolated and is kept in the sun room during the day due to behavior.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 2