<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708394
Report Date: 08/04/2022
Date Signed: 08/22/2022 11:33:25 AM


Document Has Been Signed on 08/22/2022 11:33 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
CENTRAL COAST CR/RES, 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:
08/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Maria Erene Bautista and Serapia BeltranTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mandeep Kaur conducted an unannounced Case Management visit and met with Administrator Maria Erene Bautista and Licensee Serapia Beltran. The purpose of the case management visit was to follow up an an incident report that the facility submitted to the Department on 07/27/2022. The incident report stated that Administrator Maria Erene Bautista admitted to Hospice Nurse on 07/21/2022 that resident R1 was given un-prescribed COVID medication that was prescribed to another resident. The incident report states that Licensee Serapia Beltran (PIA) provided the written and verbal warning to administrator Maria Erene Bautista.

LPA Mandeep Kaur spoke with Administrator Maria Erene Bautista and Licensee Serapia Beltran on 08/04/2022 and they stated that R1 has passed away on 07/24/2022 due to health declining reasons for last two weeks. Administrator and Licensee stated that R1 was under hospice care and death was due to declining health conditions, not because of the medication error. Licensee Serapis Beltran stated that training was provided to Administrator and Training log was reviewed.


No deficiency was cited as per California Code of Regulations Title 22. Advisory notes issued. LPA reviewed the Medication log, Medication training log for the administrator.

This report was reviewed with Administrator Maria Erene Bautista and Licensee Serapia Beltran and a copy of this report and advisory notes are provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1