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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202376
Report Date: 10/15/2021
Date Signed: 10/20/2021 12:20:28 PM

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:BONNEVIE RESIDENCE AND CAREFACILITY NUMBER:
435202376
ADMINISTRATOR:RAMIRO CUSTODIOFACILITY TYPE:
740
ADDRESS:555A MC LAUGHLIN AVENUETELEPHONE:
(408) 931-6077
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:6CENSUS: 5DATE:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Ramiro CustodioTIME COMPLETED:
12:05 PM
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On 10/15/2021 at 10:28 am, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced Annual Required 1 Year visit. LPA met with Administrator Ramiro Custodio.

LPA toured the facility beginning with the main entrance. The entrance had a thermometer, hand sanitizer, and sign-in log. Temperature was taken and screening questions were asked, but both were not documented. LPA recommended screening questions and temperature to be documented. Facility is taking daily resident and staff temperatures, but only resident temperatures are being documented. LPA recommended staff to document their daily temperature check.

Universal precautions, COVID-19 protocols, and social distancing guidelines were posted throughout the facility. Restrooms had hand soap and paper towels readily available. Facility had at least 30 day supply of medications for the residents.

Staff were observed wearing a mask and following COVID-19 protocols. Facility observed to have adequate supply of PPE.

An advisory note was issued, please see LIC 9102. No deficiencies were cited during today's visit.

This report and advisory note were reviewed with Administrator Ramiro Custodio and copies were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna BuiTELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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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