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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202934
Report Date: 07/26/2024
Date Signed: 07/26/2024 10:50:46 AM

Document Has Been Signed on 07/26/2024 10:50 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:BONITA SPRINGS CARE HOMEFACILITY NUMBER:
435202934
ADMINISTRATOR/
DIRECTOR:		CERA, DULCE ROSE GFACILITY TYPE:
740
ADDRESS:853 GERONIMO STREETTELEPHONE:
(408) 841-0248
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 0DATE:
07/26/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Dulce Cera and Oman ***TIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived announced to conduct the pre-licensing inspection. LPA met with Dulce Rose Cera and Syeda Mamoona Omer.

The facility has an approved fire clearance for 6 non-ambulatory, in which 1 may bed bedridden. Bedridden residents is approved to reside in room #5.

During visit, LPA toured the interior to include 5 resident bedrooms, 1 staff bedroom, bathrooms, living room, dining room, kitchen, garage, and exterior. All fire exit routes are free and clear of obstruction. Exit routes contains ramps. Fire extinguisher last serviced on 02/09/2024. Carbon monoxide detector, complete first aid kit, and emergency lightings observed present. The backyard contains a shed and observed with storage items. Interior temperature maintained at 71 degrees Fahrenheit. Kitchen is equipped with a locked cabinet to store items that will be kept inaccessible to residents. LPA observed sufficient cups, plates, bowls, and utensils. Facility is equipped with at least 7 days worth of non-perishables and 2 days worth of perishable foods. Refrigerator temperature maintained at 37 degrees Fahrenheit. Freezer temperature maintained at -1 degrees Fahrenheit. Bedrooms equipped with beds, linens, adequate lighting, chair, night-stand, and dresser. Hot water temperature maintained at 106 degrees Fahrenheit. Bathroom shower contains non-slip mats. Bathroom #1 and #5 observed with a grab bar. Laundry room observed with locked cabinets. Facility has an area to lock medications and records. Posters observed to include the licensing complaint poster, ombudsman, personal rights, rights of resident council, house rules, activities, and emergency disaster plan. COMP III completed with Dulce Rose Cera, Syeda Mamoona Omer, and Syeda Lubna Haroon

No issues noted during the pre-licensing inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. This report was reviewed with Dulce Rose Cera and Syeda Mamoona Omer and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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