435202376-10-20-2026-26-AS-MPAA-DZ2UVL-20261020155520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202376
Report Date: 10/15/2026
Date Signed: 10/20/2026 03:57:44 PM

Document Has Been Signed on 10/20/2026 03:57 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:	BONNEVIE RESIDENCE AND CARE		FACILITY NUMBER:	435202376
ADMINISTRATOR/ DIRECTOR:	MERCLO GARCIA		FACILITY TYPE:	740
ADDRESS:	555A McLaughlin AVE		TELEPHONE:	(408) 931-6077
CITY:	San Jose	STATE: CA	ZIP CODE:	95116
CAPACITY: 6		CENSUS: 4	DATE:	10/15/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Merclo Garcia		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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	On 10/15/2026, at approximately 0915 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced 1 year required inspection. LPA was greeted by 2 staff, Ramiro Custodio (S1) and Merlinda Garcia (S2). S1 stated that Licensee/Administrator (LIC/ADM) will be available at 2:00 p.m. after S1s shift ends. The facility is licensed to serve 6 adults 60 and over. 2 are ambulatory on the 2nd floor Bedroom #5 and #6 and 3 non-ambulatory on the first floor, approved for 1 bedridden in room #3, and 2 hospice waiver. At approximately 9:30 a.m. LPA conducted a tour of the facility and inspected the entry way, living room, dining room, kitchen, 4 resident's bedroom and 2 bathrooms and exterior perimeter. LPA observed that the facility's entry way has posters for personal rights, Long Term Care Ombudsman (LTCO), CDSS complaint information (Letusno). The hallways and walkways inside the facility were free from tripping hazard and free from obstruction. The living area was organized and sanitary. On the first floor LPA observed 3 resident bedroom, 1 shared and 2 private rooms, a bathroom with grab bars and anti skid mats were observed, a storage under the staircase contains linens and other supply such as diapers, and bed protection and supplies for hospice care, the storage also contains the emergency water bottles. page 1 of 3

Romeo Manzano
Maria Partoza
	DATE: 10/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BONNEVIE RESIDENCE AND CARE	FACILITY NUMBER: 435202376
	VISIT DATE: 10/15/2026

NARRATIVE

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The rooms on the ground floor and bathroom were sanitary and organized and chemicals were locked and not accessible to residents. S1 stated that 1 out of 4 resident is under hospice care and 1 out of 4 was not present due to medical appointment and 2 out 4 were at the facility in their respective rooms.

LPA inspected the kitchen and observed that the food pantry is organized and sanitary. The knives were locked and not accessible to residents in care. The kitchen is equipped with essential appliances such as stove and oven combination, refrigerator and dishwasher. The facility has 2 days of perishable food and 7 days of non-perishable food supply. The refrigerator temperature is within regulation of 38 degree F and freezer temperature is at 0 degree F. LPA observed that the medications were kept locked in a cabinet inside the staff office.

On the 2nd floor the facility has 2 rooms used by staff and 1 hallway bathroom. LPA observed that emergency exit route map was placed strategically throughout the facility. LPA observed that the facility has a pull fire alarm system mounted on the wall by the entry way. LPA observed 2 fire extinguishers one in the kitchen and one on the second floor that was last inspected on 04/23/2026. S1 stated that the pull fire alarm is active and can be used in case of emergency. The facility is equipped with smoke and carbon monoxide alarm and was in good working condition when tested.

LPA measured the hot water temperature in the kitchen and 2 bathrooms with a digital thermometer. The facility's water temperature is at 112.6 degree F.

LPA reviewed 4 resident records. Based on interview, LIC/ADM stated that weight record for R3 is monitored by staff and weight record is sent to R3s responsible party. R1s weight is monitored by his/her primary care physician (PCP) during his/her routine check up 3 times a week. R4's have quarterly wellness check up with their PCP. R2 limits his/her visit with the PCP and visits his/her PCP on a yearly basis. Based on interview LIC/ADM stated that R2 would sometimes refuse to visit his/her PCP. LIC/ADM stated that all after visit for R2 and R4 are filed and recorded. page 2 of 3

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026

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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BONNEVIE RESIDENCE AND CARE	FACILITY NUMBER: 435202376
	VISIT DATE: 10/15/2026

NARRATIVE

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Based on CCR Title 22 87466 Observation of the resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person.

LPA issued a technical assistance for to LIC/ADM to help assist and monitor R2s possible changes in R2s condition once observed.

Based on record review 3 out of 4 resident's (R1, R2 and R4) centrally medication record were current and complete. 1 out of 4 resident (R3) is monitored by the hospice staff and administered by hospice staff.

LPA reviewed 4 staff record and observed that the staff training, background clearance, criminal record clearances, mandated reporters, special health needs training and 1st aid/CPR training were current. The facility conducts disaster preparedness training and training was conducted in July 2026 for fire and earthquake.

No deficiencies is being cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with Licensee/Administrator Merclo Garcia, and a copy of the report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026

LIC809 (FAS) - (06/04)

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