435202376-5-11-2021-26-AS-KHOS-C3CL39-20210525082334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202376
Report Date: 05/11/2021
Date Signed: 05/11/2021 11:21:26 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2021 and conducted by Evaluator Anna Bui

COMPLAINT CONTROL NUMBER: 26-AS-20210316125221

FACILITY NAME:	BONNEVIE RESIDENCE AND CARE		FACILITY NUMBER:	435202376
ADMINISTRATOR:	SILVESTRE, JESUSJESSIEJAME		FACILITY TYPE:	740
ADDRESS:	555A MC LAUGHLIN AVENUE		TELEPHONE:	(408) 931-6077
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY:	6	CENSUS: 6	DATE:	05/11/2021
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Ramiro Custodio		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Facility not operating at a comfortable temperature.

INVESTIGATION FINDINGS:

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On 05/11/2021 at 10:18 am, Licensing Program Analyst (LPA) Anna Bui conducted a complaint investigation televisit to deliver the finding to the above allegation. Due to COVID-19 health pandemic, LPA virtually met with Ramiro Custodio, Administrator.

On 03/19/2021, 4 residents were interviewed. 4 out of 4 residents stated the temperature at the facility is fine and staff either adjusts the temperature or provides portable heaters when it is too cold or hot.

On 03/19/2021, 1 staff (S1) was interviewed. S1 stated the heater was broken but the Property Manager was notified immediately and was sending someone to fix it. S1 stated portable heaters are provided for each room at the facility.

-Continued, see LIC 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210316125221

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BONNEVIE RESIDENCE AND CARE	FACILITY NUMBER: 435202376
	VISIT DATE: 05/11/2021

NARRATIVE

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On 03/19/2021, the facility’s thermostat was observed at 75 degrees Fahrenheit, which is within the temperature range stated in Title 22 regulations. Portable heaters were observed available for residents as well.

On 05/11/2021, the new Administrator (S2) was interviewed. The Administrator (S2) stated the heater was fixed on 03/25/2021 and it is now working properly.

The Department has investigated the above allegation. Based on interviews and observation, the Department has determined that the allegation was UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Ramiro Custodio, Administrator, and a copy of this report was emailed to Ramiro Custodio, Administrator, on 05/11/2021 for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

LIC9099 (FAS) - (06/04)

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