<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202934
Report Date: 08/11/2025
Date Signed: 08/11/2025 05:20:49 PM

Document Has Been Signed on 08/11/2025 05:20 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:BONITA SPRINGS CARE HOMEFACILITY NUMBER:
435202934
ADMINISTRATOR/
DIRECTOR:		HAROON, SYEDA LUBNAFACILITY TYPE:
740
ADDRESS:853 GERONIMO STREETTELEPHONE:
(408) 841-0248
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
08/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Dulce Rose Cera TIME VISIT/
INSPECTION COMPLETED:
05:30 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
Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. Administrator, Syeda Haroon was contacted but was unavailable during time of visit. LPA met with designated Administrator, Dulce Rose Cera

During visit, LPA toured the facility to include 5 resident bedrooms, 2 bathrooms, living room, kitchen, dining room, laundry room, garage, backyard and exterior. All emergency exit routes were free and clear of obstruction. The front door and backyard door observed with operable door alarms. There was 2 staff present to 6 residents. Both staff are fingerprint cleared and associated to the facility.

Facility temperature maintained at 77 degrees F. Fire extinguisher last serviced on 06/17/2025. Carbon monoxide detector present and observed operable. Facility has at least 2 days worth of perishables. LPA observed only 24 cans of non-perishable foods in the facility for 6 residents. LPA observed additional items of non-perishable foods to include 3 packages of crackers, 1 pack of cookies, 1.5 packs of apple sauce, and container for cereal. Facility was provided a technical advisory on Title 22 regulation Section 87555 - General Food Service Requirements advising that the facility shall maintain minimum of 7 days worth of nonperishable foods at all times. Refrigerator temperature maintained at 37 degrees F. Freezer temperature maintained at -2 degrees F. Items inside the refrigerator observed covered and labeled.
Page 1 of 3.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2025
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
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)
Page: 2 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: BONITA SPRINGS CARE HOME
FACILITY NUMBER: 435202934
VISIT DATE: 08/11/2025
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
26
27
28
29
30
31
32
 The chemicals, disinfectants, and toxins are stored separately from the food supply. The drawer and cabinet containing sharp objects, chemicals, and disinfectants observed closed with a lock but LPA observed the drawer and cabinets were unlocked upon opening. All resident's are non-ambulatory and require staff assistance when ambulating. During visit, facility staff locked the cabinets and drawers that contains sharps and toxins. Facility was provided a technical advisory on Title 22 regulation on Section 87309(a) - Storage Space and Access. Designated Administrator stated understanding.

Resident bedrooms equipped with beds, linens, dressers, night stand, and adequate lighting. Bathroom equipped with grab bars in the shower and next to the toilet and non-slip mats in the shower. Hygiene products and paper supplies observed. Bathroom hot water temperature in the hallway and master bedroom was measured. The hallway hot water temperature measured at 135.6 degrees F and the master bedroom hot water temperature maintained at 136.5 degrees F. A type A deficiency is being cited today in violation of Title 22 Section 87303 - Maintenance and Operation for the hot water temperature exceeding 120 degrees F.

There are 2 residents under hospice care. Bedroom #2, #3, and #4 equipped with full bed rails in which 1 out of 3 residents are under hospice care and the physician's order for full rails is listed in the hospice care plan. 2 out of the 3 resident's (R1 & R2) is not under hospice care but utilizes full bed rails. Based on review of the facility file, the facility did not request for an exception for the use of full bed rails nor did the facility obtain a physician's order for the full rails. Facility was advised. A type A deficiency is being cited today in violation of Title 22 Section 87608 - Postural Supports wherein 2 residents who are not receiving hospice care is utilizing full length bed rails which are prohibited unless granted approval from the Department.

4 resident files were reviewed. 3 out of 4 resident files were observed complete and up-to-date. 1 out of the 4 resident's (R1) file did not contain a medical assessment prior to admission. A type B deficiency is being cited today in violation of Title 22 Section 87458 - Medical Assessment wherein the facility did not obtain a physician's report prior to admitting R1.
Page 2 of 3.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025
LIC809 (FAS) - (06/04)
Page: 3 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: BONITA SPRINGS CARE HOME
FACILITY NUMBER: 435202934
VISIT DATE: 08/11/2025
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
26
27
28
29
30
31
32
 3 out of 4 residents centrally stored medications and centrally stored medication records (CSMR) were reviewed and issues were noted for resident R2 - R4. There was 2 medications not written in the CSMR for R2, 6 medications not written in the CSMR for R3, and 2 medications not written in the CSMR for R4. A type B deficiency is being cited today in violation of Title 22 Section 87506(a) - Resident Records wherein 3 residents (R2 - R4) centrally stored medications were not maintained as there was a total of 10 medications that were not written in the CSMR.

3 staff files were reviewed and observed complete to include an active first aid certification, fingerprint clearance, health screening, TB result, and annual training per Title 22 regulations.

Facility has an emergency disaster plan and LPA advised Administrator to update the emergency disaster plan annually. Facility has emergency lighting available when needed. First aid kit observed. Based on record review, the emergency drills were completed in 2024 but during visit, there was no record to show the emergency drills were completed for this year. The last drill completed and recorded was for December 2024. A type B deficiency is being cited today in violation of Title 22 HCS 1569.695(c) as the facility has not completed quarterly emergency drills as required.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note also provided.

This report was reviewed with designated Administrator, Dulce Rose Cera and a copy of the report and appeal rights were provided.

Page 3 of 3.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 08/11/2025 05:20 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/11/2025 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BONITA SPRINGS CARE HOME
FACILITY NUMBER: 435202934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (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).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on obseration, the licensee did not comply with the section cited above wherein the hot water temperature in the hallway and master bedroom was measured at 135.6 and 136.5 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2025
Plan of Correction
1
2
3
4
Licensee will adjust the hot water temperature today. Licensee states going forward, they will create a hot water log for staff to monitor the hot water temperature daily. Licensee will submit the hot water log and temperature of the water for the evening of 08/11/2025 to LPA Kabariti via email by POC due date of 08/12/2025.
Type A
Section Cited
CCR
87608(a)(5)(B)
(a) ... Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 2 residents who are not receiving hospice care utilizes full bed rails which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2025
Plan of Correction
1
2
3
4
Licensee states a plan to remove the full bed rails today and obtain a physician's order for the bed rails. Licensee will submit a photograph of the bed after the rails have been removed and submit a written plan for going forward to LPA Kabariti via email by POC due date on 08/12/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 08/11/2025 05:20 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/11/2025 at 04:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BONITA SPRINGS CARE HOME
FACILITY NUMBER: 435202934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in wherein there was no record to show that emergency drills were completed this year as the last documented drill was completed in December 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
1
2
3
4
Licensee will complete the emergency drills for this month. Licensee will send the emergency drill log to LPA Kabariti via email by POC due date of 08/18/2025.
Type B
Section Cited
CCR
87458(a)
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 1 resident who was admitted to the facility did not have a physician's report on file prior to admission which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
1
2
3
4
Licensee will submit a copy of the resident's physician's report as part of the plan of correction, to LPA Kabariti via email by POC due date of 08/18/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 08/11/2025 05:20 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/11/2025 at 04:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BONITA SPRINGS CARE HOME
FACILITY NUMBER: 435202934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review the licensee did not comply with the section cited above wherein 3 resident's centrally stored medications records (CSMR) were not maintained as there was a total of 10 medications that was not written in the CSMR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
1
2
3
4
During visit, the designated Administrator inputted all the medications that was missing in the 3 residents centrally stored medication record. To hold the licensee accountable, the licensee will correct the deficiency by conducting a staff training on medications with a licensed professional. Licensee will submit the staff training to LPA Kabariti via email by POC due date 08/18/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9