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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201336
Report Date: 08/07/2024
Date Signed: 08/07/2024 03:57:14 PM

Document Has Been Signed on 08/07/2024 03:57 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 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:
08/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Shirley BordonTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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At around 2pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct pre licensing inspection and met with Licensee/applicant Shirley Bordon. LPA explained to Shirley the purpose of the visit. The facility is currently licensed as a children's residential home and is transitioning to Adult Residential Facility (ARF). The Administrator authorized staff Leon Noel Branal to sign the report.

The facility has an approved fire clearance for 1 non ambulatory and 3 ambulatory clients. During the visit, there was one client and two staff present. LPA inspected the facility inside and out including but not limited to client bedrooms, kitchen, sun room, backyard, bathroom. Hot water temperature measured at 110 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. Multiple fire extinguishers that appeared full and were last serviced on 2/13/2024 were observed. There were no bodies of water observed. Passageways and hallways were free of obstruction There was sufficient lighting and furniture appropriate. First aid kit was observed complete.
Medicines were observed locked in a steel cabinet in the living area. Smoke detectors and carbon monoxide detectors were tested and observed functional.

The facility has surety bond sufficient to cover amount of cash being handled at one time.

LPA interviewed two staff during the visit.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2024
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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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 III
FACILITY NUMBER: 019201336
VISIT DATE: 08/07/2024
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LPA did not observe deficiencies during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB.

Additional requirements may still be required.

Exit interview was conducted with Branal and a copy of this report was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
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