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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708394
Report Date: 08/28/2024
Date Signed: 09/05/2024 10:31:50 AM


Document Has Been Signed on 09/05/2024 10:31 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:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Maria Erene BautisaTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Maria Erene Bautisa and stated the purpose of today's visit. LPA Rai observed 2 staff and 5 residents at the facility. There are 4 residents receiving hospice services.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the resident bedrooms. 5 Out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 112.3 - 118.2 degrees F. The water temperature in the kitchen sink was 109.8 degrees F.

Fire extinguisher was observed and inspected on 06/18/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills were conducted on 06/05/2024 and 03/08/2024.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records.

No deficiencies were cited per California Code of Regulations, Title 22. Technical Violation was provided. This report was reviewed with Administrator, Maria Erene Bautisa and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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