430708594-8-28-2021-26-AS-CCHG-C6BMA6-20210828092545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430708594
Report Date: 08/27/2021
Date Signed: 08/28/2021 09:27:29 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 DRIVE		FACILITY NUMBER:	430708594
ADMINISTRATOR:	ROMULDEZ, JONA		FACILITY TYPE:	740
ADDRESS:	2795 LENA DRIVE		TELEPHONE:	(408) 448-0905
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	6	CENSUS: 6	DATE:	08/27/2021
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Gladys Smart, ADM		TIME COMPLETED:	10:15 AM

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) Steve Chang, Licensing Program Manager (LPM) Romeo Manzano and Program Clinical Consultant (PCC) Cristina Wong conducted Techical Assistant PCC through tele-inspection, and met with Administrator (ADM) Gladys Smart. The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus. During visit, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance to include screening questionnaire forms, hand sanitizer, face masks, thermometer, and a visitor log book. The facility common areas were inspected such as the kitchen, living room, bathrooms were observed. Staff were observed wearing Personal Protective Equipment (PPE). Staff demonstrated the proper doffing and donning of PPEs and proper hand washing. Facility bathrooms signage on hand washing, gloves, disinfecting soap, paper towel boxes were observed, and trash cans with covers were observed. The laundry room was observed and inspected. Continued, see LIC 809-C.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 DRIVE	FACILITY NUMBER: 430708594
	VISIT DATE: 08/27/2021

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ADM stated the dining area only allows one people to stay at one time. ADM stated there is one bathroom dedicated for positive case. ADM stated the positive case residents are only allowed to stay at their rooms or in the dedicated bathroom. ADM stated the laundry loads were separated from positive case people and non-positive case people.
The facility has 6 residents and 7 staff with 2 residents tested COVID positive and 6 staff tested COVID positive. One staff is isolating in Hotel, three staff are isolating at facility, two staff are isolating at their house, one resident is isolating at facility, and one resident is hospitalized.

Based on today's inspection, the facility is being recommended the following:

1. Licensee to put face mask signage on the facility main entrance door and throughout the
facility.
2. Licensee to incorporate or include symptoms on COVID-19 questionnaire.
3. Licensee to assign a specific staff to do the screening to staff and/or visitors.
4. Licensee to put additional hand sanitizers in the facility and to offer residents to sanitize
hands.
5. Licensee to disinfect more often for high touch areas.
6. Licensee to put signage on bathrooms designated only for COVID positive
staff/residents.
7. Licensee to put a signage on the isolation bedrooms.
8. Licensee to ensure the paper towel boxes are not wet and to keep it dry.
9. Licensee to adhere to the procedures of donning and doffing PPE.
10. Licensee to ensure that there is no crossing over between positive and negative
staff/residents.

No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to the facility for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC809 (FAS) - (06/04)

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