435202592-7-31-2026-26-AS-MMOR-DWHNY2-20260731105200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202592
Report Date: 07/31/2026
Date Signed: 07/31/2026 10:52:13 AM

Document Has Been Signed on 07/31/2026 10:52 AM - 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:	FOOTHILL ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	435202592
ADMINISTRATOR/ DIRECTOR:	BONNIE L JIRACEK-CODD		FACILITY TYPE:	735
ADDRESS:	13655 FOOTHILL AVE		TELEPHONE:	(669) 231-3861
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY: 4		CENSUS: 4	DATE:	07/31/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Administrator Bonnie Jiracek-Codd		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

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 July 31, 2026, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management - incident visit regarding an incident report regarding resident R1. LPA met with Administrator Bonnie Jiracek-Codd and explained the purpose of the visit. On July 27, 2026, the Department received an incident report (IR) regarding resident R1. The incident report stated, on July 25, 2026, at approximately 10:30am, R1’s 1:1 staff went to R1’s bedroom to prompt him/her to start his/her morning activity, his/her laundry. After a few minutes the Lead staff went to check on R1’s progress and his/her 1:1 staff reported R1 continued to refuse his/her prompts to start his/her laundry. Upon returning to the office, R1 approached the office door and informed the Lead staff that he/she did not want to work with his/her 1:1 staff, S1, stating he/she called him/her a “dumbass”. The Lead staff then spoke with S1 about what had been reported. S1 denied calling R1 a “dumbass” and stated he/she had redirected R1 to start his/her laundry. During a conversation between R1 and the Administrator via cellphone, R1 stated that S1 said, “I was stupid, a lazyass and a dumbass ”. R1 explained they had exchanged some words / slurs after S1 repeated prompts and his/her repeated refusal to do his/her laundry. R1 then stated that S1 called him/her a “lazyass and said I was stupid and a dumbass and who do you think staff are they going to believe, you or me”. R1 stated he/she responded to S1 saying “fuck you bitch”. The Administrator asked R1 what was said, and R1 stated, “he/she had called me stupid and said I was a lazyass and a dumbass”. He/she also stated, “he/she said who are the staff going to believe you or me, and I don’t know why he/she said that to me”.

Romeo Manzano
Manuel Monter
	DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

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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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: FOOTHILL ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 435202592
	VISIT DATE: 07/31/2026

NARRATIVE

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On July 31, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator Bonnie Jiracek-Codd, referred to as ADM. ADM stated she was not at the home the day of the incident. ADM stated their third party human resources conducted the investigation of the allegations. ADM stated based on the investigation, there was no witnesses to the event or anyone within earshot.

The Department reviewed R1's Behavior Agent data. (BAD) Based on a review, the BAD states, on July 25, 2026, at 10:38am, R1 called S1, bitch, dumb bitch, fat ass, and said fuck you 3 times. This event took place in the bedroom. The antecedent was avoiding cleaning his/her room. This note was written by staff S1.

Based on investigation, records reviewed, and interviews conducted, the Department found that the allegation that staff S1 verbally abused resident R1 as UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

A technical violation was cited during this visit.This report was reviewed with Administrator Bonnie Jiracek-Codd and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

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: FOOTHILL ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 435202592
	VISIT DATE: 07/31/2026

NARRATIVE

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The Administrator spoke to S1, who denied calling R1 names and when the Administrator again asked if he/she had called him/her stupid, lazyass or a dumbass, this time said, “well I did tell him/her he/she was lazy, and he/she got confused saying I called him/her dumb when I called him/her a name” ( the name that sounded like the word dumb). ADM told S1 to please write a statement and asked him/her to leave as he/she was suspended until further investigation was completed. As the Administrator was hanging up the phone, he/she could hear S1 say, “wow he/she really has it out for me”.

On July 30, 2026, Licensing Program Analyst Manuel Monter interviewed Staff S1. S1 stated the day of the incident, he/she had clocked in at 10:00am and was informed by the previous shift that R1 was starting his/her laundry. S1 stated he/she was prompting R1 to get him/her to work on his/her laundry. S1 stated he/she made multiple prompts to get R1 to do his/her laundry. S1 stated he/she told R1 "hey R1, you gotta quit being lazy, we only have 2 things to do today: your laundry and cleaning your room, then you can relax." S1 stated R1 was silent then went to staff S2 to talk about his/her interaction with S1.

S1 denied ever calling R1: lazyass, dumbass. S1 acknowledged that he/she did call R1 lazy when he/she was trying to encourage him/her. S1 stated he/she did not call R1 "dumb." S1 stated he/she called R1 a nickname, that other staff in the home have used.

On July 31, 2026, Licensing Program Analyst Manuel Monter interviewed staff S2-S3. S2 stated he/she was not in the home when the incident occurred. S2 stated based on his/her observations he/she has never seen or heard S1 interacting with residents in a negative or disrespectful manner.

S3 stated he/she was working at the home the day of the incident. S3 stated around 10:30am, he/she went to check on R1 and S1. S3 stated after checking on them, she returned to the office. S3 stated 2 minutes later, R1 came to the office and wanted to inform S3 about his/her interaction with S1. LPA asked S3 when he/she was checking R1 and S1, was there any other staff or residents in that immediate area or within earshot. S3 stated he/she did not see or hear the interaction between R1 and S1.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

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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