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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708394
Report Date: 07/27/2021
Date Signed: 07/29/2021 02:10:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BONHOMIE IFACILITY NUMBER:
430708394
ADMINISTRATOR:ROMUALDEZ, JONA D.FACILITY TYPE:
740
ADDRESS:1139 DWYER AVENUETELEPHONE:
(408) 268-0328
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY:6CENSUS: 5DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Gladys SmartTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Administrator Gladys Smart.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, and hand sanitizer were present at the entrance. LPA was temperature checked and was asked to sign in upon entry.

LPA toured the facility. The facility was observed to be in sanitary condition. COVID-19 signs were posted at the entrance and hallway. All staff members were observed to be wearing masks.

LPA inspected 2 restrooms. The restrooms were observed to be adequately stocked with paper towels and hand soap. Trash bins with lids were present. Hand washing signs were posted inside the restrooms.

Facility was observed to have a supply of PPE in the storage area. A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) from the facility was received. LPA discussed the infection control with the Administrator. 5 residents and 2 on duty staff were fully vaccinated per Administrator.

No deficiency cited during visit. However, advisory notes (LIC 9102) were issued.

This report was reviewed with the Administrator. A copy of this report and advisory notes were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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