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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601313
Report Date: 02/20/2025
Date Signed: 02/20/2025 05:22:09 PM

Document Has Been Signed on 02/20/2025 05:22 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:BEGONIA RESIDENTIAL CARE HOMEFACILITY NUMBER:
015601313
ADMINISTRATOR/
DIRECTOR:		BOLLOSO, JOVITAFACILITY TYPE:
740
ADDRESS:34814 BEGONIA STREETTELEPHONE:
(510) 429-7250
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:35 PM
MET WITH:Jovita Bolloso, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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During an annual on 2/20/2025 at 10:40 a.m., LPA, K. Nguyen reviewed S1 file and observed current First Aid/CPR and fingerprint clearance but are not associated to the facility. LPA check with guardian and verfied that S1 is not associated to the facility.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties.

*An immediate $100.00 civil penalty will be assessed on today's date for reported violation within 12month. *

Exit interview conducted. A copy of the LIC421FC, this report and appeal rights provided.
Bennett FongTELEPHONE: (510) 725-7919
Kelly NguyenTELEPHONE: (510) 915-8702
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2025 05:22 PM - It Cannot Be Edited

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: BEGONIA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2025
Section Cited
CCR
87355(c)

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87355 Criminal Record Clearance
(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department:
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Administrator agree to associate S1 to the faciliyt and submit proof to CCLD by POC date.
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Base on files reviewed, and interview S1 file and observed current First Aid/CPR and fingerprint clearance but are not associated to the facility.
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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.
Bennett FongTELEPHONE: (510) 725-7919
Kelly NguyenTELEPHONE: (510) 915-8702

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025

LIC809 (FAS) - (06/04)
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