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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708594
Report Date: 08/19/2022
Date Signed: 08/19/2022 03:36:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/19/2022 03:36 PM - 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 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:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Monette Encina, TIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Monette Encina .Upon arrival, HM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with HM. COVID posters were observed at main entrance andin the facility. Screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room and three restrooms were inspected. All trash cans were observed with covers. Paper towels were observed with holders. Posters of washing hands for 20 seconds were observed by the sinks of kitchen and restrooms. Two single resident bedrooms, two resident shared bedrooms, and laundry room were inspected. Beds in shared rooms were observed 6 feet apart. Two staff live-in rooms were observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 74 degree F, and hot water temperature was at 106 degree F in facility. Six residents and 2 staff were observed in facility.

Fire extinguisher was serviced on 06/10/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

HM stated all the residents and staff are fully vaccinated and done with boosters. The facility already submitted LIC9282, Infection Control Plan to LPA. No deficiency or citation were noted today. Exit interview was conducted with HM. This report was provided to HM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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