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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202376
Report Date: 10/31/2024
Date Signed: 10/31/2024 08:38:03 PM

Document Has Been Signed on 10/31/2024 08:38 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 CAREFACILITY NUMBER:
435202376
ADMINISTRATOR/
DIRECTOR:		RAMIRO CUSTODIOFACILITY TYPE:
740
ADDRESS:555A MC LAUGHLIN AVENUETELEPHONE:
(408) 931-6077
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ramiro CustodioTIME VISIT/
INSPECTION COMPLETED:
08:45 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Marcela Yanez and Mita Partoza. Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced Required 1 Year visit and met with Merclo Garcia Administrator, 3 staff-Bienvenido (Ben) and Ramiro Custodio (brothers), and Mary Wacheke and met with 5 residents (R1 to R5).

During inspection LPAs observed a total of 7 bedrooms (1 of which is the upstairs office converted into a room which is not being utilized as a staff bedroom). Based on physical floor plan submitted to the department and during initial application, there are only 2 bedrooms on the first floor (#1 & #2) and 2 bedrooms on second floor (bedroom#3 and caregiver bedroom (no designated number) adjacent to the second floor stairway next to the bathroom. A review of the approved 3 STD 850 dated on 11/7/13 and 11/18/2013 are approved for 2 ambulatory and 4 non-ambulatory and on 12/4/2013, fire clearance change from 2 ambulatory, 3 non-ambulatory and 1 bedridden clearance in bedroom #2 on 1st floor. An overall analysis of the facility fire clearance, the facility is currently approved for 2 Ambulatory and 3 Non-Ambulatory and 1 bedridden clearance (as it states #1 and #2 on first floors are either ambulatory and/or non-ambulatory) and Bedroom #3 is ambulatory only and an office on the second floor.

On 7/1/2024, Mr. Merclo Garcia was elected by the officers of the corporation the corporation as the new president/Administrator and Ramiro Custodio, a corporate member. Mr. Merclo stated that the former board members (Edralyn Lanzi and Rochelle Basco) stated that when they took over of the facility in 2013 from the previous licensee, the facility bedrooms already existed which is contrary to the submitted floor plan and fire clearances on file by Ms. Lanzi and Ms. Basco.

Mr. Garcia will contact the former board members for additional information about the facility physical floor plan including the landlord and to contact the San Jose Fire Marshal to obtain history and building permits of the facility property building.

The Department did not issue a citation on the discrepance of the fire clearance but advised to immediately contact SJFD and to submit a new fire clearance and updated new/updated floor plan request to CCLD before COB 11/1/2024. Page 1 of 3
Romeo ManzanoTELEPHONE: (650) 388-2297
Marcela YanezTELEPHONE: (279) 789-1062
DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 9
Document Has Been Signed on 10/31/2024 08:38 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: BONNEVIE RESIDENCE AND CARE
FACILITY NUMBER: 435202376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)(2)


This requirement is not met as evidenced by:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
Deficient Practice Statement
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Based on inspection LPA measured the water temperature with a digital thermometer at 145.7 degrees F in bathroom #1, 130.1 in bathroom #2 and 141.1 in bathroom #3 (2nd Floor)
POC Due Date: 11/01/2024
Plan of Correction
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Administrator stated they will do a weekly check to maintain required level of measurement ranging from 105 to 120 degrees F. Administrator will submit a written plan of action by POC date 11/01/2024
Type A
Section Cited
CCR
87309(a)(1)


This requirement is not met as evidenced by:
(a)(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed the followiing toxic materials accessible to residents in care the following areas: #1. Car Wax and Curaid ointment unlocked hallway closet accross common area. #2. Comet, and cleaning supplies found in bathroom #3, #3 lighter fluid and bucket of laundry detergent was found in unlocked basement. #4 a garden potting soil/fertilizer was found outside the facility accesible.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator willl submit a written plan of action that will deligate to staff to make sure toxics are properly stored to the department by the POC date 11/01/2024,
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: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 10/31/2024 08:38 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: BONNEVIE RESIDENCE AND CARE
FACILITY NUMBER: 435202376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87457(c)(1)


This requirement is not met as evidenced by:
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
(1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors.
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above. LPA randomly reviewed resident file (R1,R2,R3,R4 R5). All 5 residents did not have appraisals needs and services plan in there files.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator will develop and submit a appraissal needs and services for each resident by the POC date 11/01/2024
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 10/31/2024 08:38 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: BONNEVIE RESIDENCE AND CARE
FACILITY NUMBER: 435202376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication audit LPA observed R1,R2,and R3's Centrallly Stored Medicatiion Log (LIC622), all 3 residents medication refilled in September 2024 were not documented on log.
POC Due Date: 11/05/2024
Plan of Correction
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Type B
Section Cited
CCR
87555(26)

(26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and inspection during facility tour LPAs observed in pantry 20 cans of fruit and tomato soup and few vegetable and protein which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Administrator will do a weekly check to maintain an adequate amount of perishable and non perishable food. Administrator will do a training for staff to make sure food is properly stored and labeled. Administrator will provide proof training and plan to the deparment by POC date 11/05/2024
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: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 10/31/2024 08:38 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: BONNEVIE RESIDENCE AND CARE
FACILITY NUMBER: 435202376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
(a) 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 inspection of the facility (inside and out), LPA observed the following: #1. Loose floorboard in the main dining area. #2. Residents bedroom had cob webs in window panel bedroom #1. #3.bedroom # 3 window screen had holes. #4. Kitchen stove and oven, microwave and refrigerator were observed to have grease,crumbs and food residue, oil spills and stains #5. Residents bedrooms carpets were unvaccumed and had stains, and residents furnitures were dusty.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator will submit a written plan of action on how he/she will keep the facility in maintenance
Type A
Section Cited
CCR
87465(i)
(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation medication was found in hallway closet accross from the common area curaid ointment which belonged to previous unknown resident R6 who was on hospice which were not distructed properly upon death or resident is no longer at facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator will submit a written plan of action how he/she will destruct medication for a hospice or non-hospice resident no longer at 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: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/31/2024 08:38 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: BONNEVIE RESIDENCE AND CARE
FACILITY NUMBER: 435202376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on inspection and observation LPAs observed bottles of pain reliever, allergy pills, antacid, osteo vitamin, herbal supplement, first aid anitbiotic ointment and 1 prescription ointment, and tube of pain releving cream in R1 unlocked closet. These medications belongs to R1 who is not able to store or administer own prescription/ OTC and store medication. R1s flonase was also found in kitchen. This poses/posed and immediate risk to resident in care.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator will submit a written plan of action to ensure medication (prescription or non prescription are stored properly.
Type A
Section Cited
CCR
87465(e)
e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPAs observed in Residents unlocked closet OTC medication. R1 buys OTC medication on their own.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator willl submit a written plan of action on how he/she will contact physcian to update if R1 is able to administer keep order or buy medication.
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: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 6 of 9
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: 10/31/2024
NARRATIVE
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Mr. Garcia will contact the former board members for additional information about the facility physical floor plan including the landlord and to contact the San Jose Fire Marshal to obtain history and building permits of the facility property building.

The Department did not issue a citation on the discrepance of the fire clearance but advised to immediately contact SJFD and to submit a new fire clearance and updated new/updated floor plan request to CCLD before COB 11/1/2024.

LPA observed 2 fire extinguishers 1 on the first and 1 second floor which were last inspected on 6/2023. LPA informed ADM to ensure that their fire extinguishers are inspected and current. The facility Fire and Earthquake log was last conducted on 07/15/2024. ADM stated that Fire and Earthquake or Disaster Drills are conducted every quarter. Smoke detector were tested and in good operating condition including carbon monoxide.

There were also at least 22 tubes of triple antibiotics cream found in hallway closet across the living area unlocked. ADM stated the these antibiotics belonged to a former resident who was under hospice (name of resident unknown). LPA discussed with ADM regarding proper destruction of unused medications.

During visit, LPAs toured the facility inside and out. LPAs observed food storage areas and locked cabinets for cleaning supplies including sharp objects. Cleaning solutions and other toxins were found accessible in the following areas bedroom, bathrooms, basement and outside underneath the ramp (all these are noted on LIC809-D).

Food supplies for 7 day non-perishable and 2 days perishables were observed. During inspection of the facility food supplies for 7 days, there were only 20 can foods comprised of fruits and tomato soup. LPAs did not observed can foods variety in protein and vegetables. Also, LPAs reminded Administrator to have an Emergency food supplies in the facility such as can foods, water, emergency disaster kits.

The facility was equipped with kitchen appliances such as but not limited to refrigerator, stove/oven and microwave. Inspections of these appliances noted to have stains, grease, crumbs and food residue wherein the Administrator was present during the inspections and photos were taken. Page 2 of 3
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9
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: 10/31/2024
NARRATIVE
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Surveillance cameras were observed during inspection visit in the following areas: carport, front/main door, living room, office (in the kitchen). ADM stated that cameras were installed or grandfather from the previous corporate members. ADM and S1 stated that cameras are recorded but no audio. LPAs advised ADM to submit a program plan for the use of surveillance cameras. Use of cameras does not specifically address on statutes, however, a waiver is needed when being used in private areas, and is allowed only in areas which does not infringe the personal rights of the residents. Audio is not allowed and is prohibited, and storing recording/records only those with legal authority to review it. ADM agreed and understood who will be submitting a program plan of the use of surveillance cameras.

All bedrooms and common areas including staff bedroom were inspected. During inspection, the facility carpet had stains, and other unknown particles; the residents furniture were not dusted, and cobwebs were observed in the windows of the resident bedrooms and window screen had holes (only in bedroom #3 window). Moreover, there was a loose floor board in the dining area (LPM almost tripped during visit).

Residents' prescribed and non-prescribed medication and the Centrally Stored Medication log residents were reviewed including their facility file record. All 5 residents did not have Appraisal, Needs and Services Plan including Consent forms wherein ADM was advised to obtain consent forms from residents' responsible parties. Staff record were also randomly reviewed, 3 staff (S1,S2,S3) files were reviewed wherein staff have a complete files including required training including first aid and/or CPR.

During random audit of 3 residents' medications records, LPAs noted that medications for 3 residents were not documented on the centrally stored log. In addition, a nasal spray belongs to R1 was observed in the kitchen shelves, and also his/her PRN medications and 1 prescribed medication found in his/her unlocked closet and door which is accessible to any residents.

Facility bathrooms were inspected equipped with non-skid mats, grab bars and handicap chairs and operational. Hygiene products and toiletries were observed and adequate.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: 10/31/2024
NARRATIVE
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The facility hot water temperatures was also measured in the following areas: in the bathroom #1 sink measured with thermometer at 145.7 degrees F in b athroom #1, 130.1 degrees F in bathroom #2 and 140.1 in bathroom #3 and 141.1 in kitchen sink.
During visit LPA suggested to remove stove knobs to prevent resident with neuro-cognitive disorder and mental illness to prevent resident from harm of fire and also discusses about facility hospice waiver stipulations such as notifying CCLD when accepting or discharging residents under hospice. and to review PIN 22-24 home health and hospice agency. LPA also suggested that door knobs should have single access mechanism for resident with neuro-cognitive disorder to access door in case of emergency or disaster. LPA informed ADM to post a Oxygen in use sign when a resident in hospice has one.

LPAs also discussed about care and supervision for the residents who are on the first floor that there should be an on-call awake staff between (10pm and 6pm) per title 22 87415. all staff reside on second floor. there are 3 resident on the first floor 1 under hospice and 1 with mental illness.

Deficiencies were cited as per California Code of Regulations Title 22, SEE LIC809-D. This report was reviewed with Merclo Garcia and Ben Custodio and a copy of this report and appeal rights discussed and provided.

This document was signed by Bienvenido Custodio on behalf of Merclo Garcia who had to leave for work and deficiencies were discussed with Merclo Garcia.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 9 of 9