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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294235
Report Date: 05/09/2024
Date Signed: 05/09/2024 12:38:29 PM


Document Has Been Signed on 05/09/2024 12:38 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:BON HOMIE SARATOGAFACILITY NUMBER:
435294235
ADMINISTRATOR:ROMUALDEZ, JONA D.FACILITY TYPE:
740
ADDRESS:12620 QUITO ROADTELEPHONE:
(408) 866-6783
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:6CENSUS: 6DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator Frances LocsinTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Frances Locsin. During the visit, LPA observed 6 residents and 2 staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. While touring bathroom #1, LPA observed a container of AJAX inside the shower. ADM stated she was cleaning when LPA arrived at the facility. ADM secured the AJAX in the locked cleaning product storage area during LPA's visit.

While touring bedrooms #1, #5 and #6, LPA observed sliding screen doors, with wooden planks on the bottom path, preventing the sliding screen door from opening. (Photographs were taken.) ADM stated it was for double safety. ADM acknowledged that for emergencies the wooden planks would be in the way.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured at 109 degrees F in resident bathrooms.

Fire extinguisher was serviced in June 19, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit. LPA requested to review the facility fire/earthquake drill log. The facility's last drill was on January 6, 2024. LPA asked ADM to review the drills conducted in the first, second and third quarter of 2023. ADM stated she did do the drills but she threw away the documentation. ADM stated she can not find the drills documentation for the first, second and third quarter of 2023. Page 1 Out of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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 5


Document Has Been Signed on 05/09/2024 12:38 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: BON HOMIE SARATOGA
FACILITY NUMBER: 435294235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed bedrooms #1, #5 and #6 's sliding screen doors, with wooden planks on the bottom path, preventing the sliding screen door from opening. ADM stated it was for double safety. ADM acknowledged that for emergencies the wooden planks would be in the way. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure all outdoor and indoor passageways and stairways shall be kept free of obstruction. ADM stated she will send the written plan of action by POC date May 10, 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: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 05/09/2024 12:38 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: BON HOMIE SARATOGA
FACILITY NUMBER: 435294235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA requested to review staff S3's training records for 2023. ADM stated she just removed the records and may have thrown them away. ADM stated she could not find them. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure staff records, including but not limited to staff training records, are available to inspect and audit. ADM stated she will send the written plan of action by POC date, May 16, 2024.
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
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Based on record review and interview, the licensee did not comply with the section cited above. LPA requested to review facility fire/earthquake drill log. The facility's last drill was on January 6, 2024. LPA asked ADM to review the drills conducted in the first, second and third quarter of 2023. ADM stated she could not find the documentation for the first, second and third quarter of 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure the facility will conduct a drill quarterly and ensure the facility has 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. ADM stated she will send the plan of action by POC date, May 16, 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: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


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: BON HOMIE SARATOGA
FACILITY NUMBER: 435294235
VISIT DATE: 05/09/2024
NARRATIVE
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LPA reviewed facility records for 3 staff and 3 residents. LPA requested to review Staff S3's training records for 2023. ADM stated she just removed the records and may have thrown them away. ADM stated she could not find them.

LPA reviewed 3 resident medications and centrally stored medication records. LPA observed resident R1-R6's Centrally Stored Medication Log (LIC622) had sections that were not filled out. The sections that were not filled out include the following; Expiration date, Date filled, Date started, Prescription number and number of refills. ADM stated she didn't have ink in her printer. ADM stated she just printed it three days ago. ADM acknowledged she should have filled out the forms before hand.

LPA conducted interviews with 1 staff and 2 residents.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Frances Locsin and a copy of the signed report was provided. Appeal Rights were provided. Due to printer error, LPA emailed a copy of the report to ADM.

Page 2 Out of 2.

END OF REPORT.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/09/2024 12:38 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: BON HOMIE SARATOGA
FACILITY NUMBER: 435294235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)(D)(E)
87465 Incidental Medical and Dental Care (h)(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 and includes...(D) The date filled...(E) The prescription number and the name of the issuing pharmacy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LPA observed resident R1-R6's Centrally Stored Medication Log (LIC622) had sections that were not filled out which included; Expiration date, Date filled, Date started, Prescription number and number of refills. ADM acknowledged she should have filled out the forms before hand. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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ADM stated she will send a written plan of action on how the facility will ensure residents centrally stored medication log is maintained with all the required information. ADM stated she will send the written plan of action by POC date, May 16, 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: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5