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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200318
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:17:25 PM


Document Has Been Signed on 05/15/2024 03:17 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BORDON HOME IVFACILITY NUMBER:
019200318
ADMINISTRATOR:SHIRLEY E. BORDONFACILITY TYPE:
735
ADDRESS:4273 DUCHESS COURTTELEPHONE:
(510) 471-3174
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 4DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Shirley BordonTIME COMPLETED:
03:30 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
On this day at around 11:20 AM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct annual required inspection. LPA was met by staff Angelica Chavez and explained the purpose of visit. Administrator Shirley Bordon arrived shortly after.

The facility is a Level 4i home vendorized by the Regional Center of the East Bay (RCEB). It has an approved fire clearance for 6 ambulatory clients. Two clients were observed present during the visit.

LPA inspected the facility inside and out including but not limited to client 3 client bedrooms, 2 bathrooms, kitchen, dining and backyard. Facility was observed clean and with sufficient lighting. There was no body of water observed. Hot water measured at 105 F in one of the bathrooms. There was sufficient supply of perishable and non perishable foods observed. Fire extinguisher in the kitchen was observed full and was last inspected 2/13/24. Carbon monoxide and smoke detector were tested and observed functional.

First aid kit was observed complete. Last fire drill was done in February 23, 2024.

LPA reviewed 4 client and 4 staff files. LPA interviewed one staff and attempted to interview two clients.

Type B deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Administrator. A copy of this report and Appeal Rights were provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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 2


Document Has Been Signed on 05/15/2024 03:17 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BORDON HOME IV
FACILITY NUMBER: 019200318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having missing wood planks in fence, ripped screen window screen window/door, dust in window sills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
1
2
3
4
By POC date, Administrator will submit photo proof of correction by POC.
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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2