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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708594
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:28:09 PM


Document Has Been Signed on 08/23/2024 03:28 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
CENTRAL COAST CR/RES, 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: 5DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Gladys SmartTIME COMPLETED:
12:23 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Gladys Smart. LPA observed 5 residents and 2 staff in the facility.3 residents files and 3 staff files were reviewed. One staff was observed not associated with the facility.

LPA toured the facility inside and out with ADM. License, ADM certificate, and personal rights posters were observed in the facility. Living room, kitchen, dinning room and three restrooms were inspected. The window glass of one of the restroom was observed broken. Grab bars and non skid mats were observed in the bathrooms. Two single resident bedrooms, two resident shared bedrooms, and laundry room were inspected. 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 were observed locked. Cleaning product closet was observed unlocked. ADM add lock and locked the cleaning product closet before LPA finished the inspection.

Room temperature was at 73 degree F, and hot water temperature was at 106 degree F in facility. The temperature of the freezer was at -10 degree F and the temperature of the refrigerator was at 40 degree F.

First aid box, flash light, and night lights were observed in the facility. The last time the facility conducted the emergency drill is on 6/4/2024.

Fire extinguisher was serviced on 06/18/2024. 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.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/23/2024 03:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III - LENA DRIVE
FACILITY NUMBER: 430708594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the window glass of one of the restroom was observed broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Administrator stated to submitted a plan of correction by the POC due date to fix the broken window glass of the restroom.
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in that staff S1 is associated with Bon Homie IV, but not associated with facility Bon Homie III which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date to associated staff S1 with the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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