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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708594
Report Date: 08/09/2021
Date Signed: 08/10/2021 08:10:56 AM

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 III - LENA DRIVEFACILITY NUMBER:
430708594
ADMINISTRATOR:ROMULDEZ, JONAFACILITY TYPE:
740
ADDRESS:2795 LENA DRIVETELEPHONE:
(408) 448-0905
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 6DATE:
08/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Gladys Smart, ADMTIME COMPLETED:
03:50 PM
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At 2:05PM, Licensing Program Analyst (LPA) Steve Chang arrived at facility, and rang the bell. Staff Monette Encina (S1) opened the door for LPA, and took LPA's body temperature. S1 conducted the COVID-19 infection questionnaire. S1 checked in LPA in the visitor log. LPA observed the COVID-19 posters in the main entrance and facility.

S1 and ADM toured LPA inside out of the facility. There are 4 bedrooms for residents and two bedrooms for staff. Two bedrooms are shared rooms for residents, and two bedroom are single rooms for residents. The beds in the shared rooms have the separators between two beds. There are two and half bathrooms in the facility. LPA observed all the trash bins in the bathrooms and kitchen have covers. The room temperature is 72 degree F. LPA inspected the food supplies. LPA observed two day perishable and seven day non perishable foods are adequate. ADM provided the roster of residents.

LPA observed staff S2 and residents (R1 - R6) in the facility.

LPA reviewed and discussed LIC808 with ADM. ADM stated all the residents and staff are fully vaccinated.

No citation was issued during today's inspection. Exit interview conducted with ADM.
A copy of this report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
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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