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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708589
Report Date: 09/13/2022
Date Signed: 09/14/2022 08:33:05 AM


Document Has Been Signed on 09/14/2022 08:33 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:BONHOMIE IV - WILLOWMONTFACILITY NUMBER:
430708589
ADMINISTRATOR:GLADYS Q. SMARTFACILITY TYPE:
740
ADDRESS:1583 WILLOWMONT AVENUETELEPHONE:
(408) 978-5211
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 6DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Gladys SmartTIME COMPLETED:
03:39 PM
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Licensing Program Analysts (LPAs) Steve Chang and Simi Rai conducted an unannounced annual inspection visit, and met with Administrator (ADM) Gladys Smart . Upon arrival, staff Reynaldo Lomero (RL) took LPAs body temperature, and checked LPAs in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at main entrance and in the facility. Screening station with masks, hand sanitizer, gloves, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room and two and half restrooms were inspected. All trash cans were observed with covers. Paper towels were observed with holders. One shared resident bedrooms, four single bed rooms and laundry room were inspected. The beds in shared room were observed 6 feet apart. There were posters of washing hands for 20 seconds were observed by the sinks in kitchen and restrooms. Cloth towels were observed in kitchen. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 73 degree F, and hot water temperature was at 112 degree F in facility. 6 residents and 2 staff were observed in facility. Fire extinguisher was serviced on 06/20/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. Swimming pool was observed at backyard. Swimming pool was observed with fence and locked.

ADM stated all the residents and staff are fully vaccinated and done with booster. The facility already submitted the Infection Control Plan. LPA checked the resident file binders. The resident file binders are up to date.

No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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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