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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201336
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:45:12 AM

Document Has Been Signed on 06/12/2024 11:45 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 IIIFACILITY NUMBER:
019201336
ADMINISTRATOR/
DIRECTOR:		BORDON, SHIRLEYFACILITY TYPE:
735
ADDRESS:4585 DARCELLE DRIVETELEPHONE:
(510) 431-3272
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 3DATE:
06/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Shirley BordonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On this day at around 10:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to
conduct pre licensing inspection. LPA met with Licensee/Applicant Shirley Bordon. LPA explained to Bordon the purpose of the visit.

While LPA was reviewing the facility's fire clearance, LPA observed the facility is approved for four ambulatory clients. However, upon interview conducted with applicant, the facility has one client who is non ambulatory.
LPA reviewed Lic 200 and observed facility applied for four ambulatory clients.

LPA advised Licensee to submit a corrected Lic 200 to CAB.

Pre licensing was not completed and will be scheduled once the corrected fire clearance is received.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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