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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601313
Report Date: 02/20/2025
Date Signed: 02/20/2025 04:24:45 PM

Document Has Been Signed on 02/20/2025 04:24 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:BEGONIA RESIDENTIAL CARE HOMEFACILITY NUMBER:
015601313
ADMINISTRATOR/
DIRECTOR:		BOLLOSO, JOVITAFACILITY TYPE:
740
ADDRESS:34814 BEGONIA STREETTELEPHONE:
(510) 429-7250
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jovita Bollisos, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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At approximately 10:00AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a Required 1 Year annual inspection and met with Staff Members, Ellen Salazar, Caregivers and explained the purpose of the visit. Jovita Bollisos, Administrator arrived at approximately 10:30AM.

LPA conducted a tour of the facility and observed the following: the facility consists of 4 bedroom and 2 bathrooms. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. There is a sufficient supply of hygiene products, paper products, and linens available for clients use.

LPA reviewed 6 Clients records, which were all complete. LPA reviewed a sample of staff records. LPA reviewed 5 staff files. Staff files were complete. Administrator's Certificate# (6011284740) was current with an expiration date of 10/26/26.

Facility's fire extinguishers were last inspected 7/15/2024. Smoke detectors and carbon monoxide detectors were tested and operational. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility have a surety bond effective 6/1/24 to 6/1/27.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 5
Document Has Been Signed on 02/20/2025 04:24 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 02/20/2025 at 03:23 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BEGONIA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked Lysol wipes in the kitchen area, and bleach underneath the sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Administrator agreed to lockup all knives and cleaning products and submit picture via email to CCLD by POC date.
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having prescribe medication unlocked in the refrigerator, kitchen cabinet, and bathroom.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Administrator agreed to lockup all medication and submit picture via email to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/20/2025 04:24 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 02/20/2025 at 03:23 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BEGONIA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 the licensee did not comply with the section cited above in emergency exit is being blocked in resident room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Administrator agreed remove the drawer block the emergency exit in client room submit picture via email to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by observed open packages of ham, cheese, ect, and vegetables that are dried inside the refrigerator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
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Administrator agreed to clean out freezer, and refrigerator and purchase more perishable food submit picture via email to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/20/2025 04:24 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 02/20/2025 at 03:23 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BEGONIA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having mouse or rat droppings underneath the sink cabinet, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2025
Plan of Correction
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Administrator agreed to clean/ schedule professional terminator to inspect the facility submit picture/ date via email to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BEGONIA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601313
VISIT DATE: 02/20/2025
NARRATIVE
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Continued on LIC809C.


Deficiencies observed by LPA during tour:
· At 12:30PM LPA observed 3 knives, and 1 scissors unlocked located in the kitchen.
· At 12:55PM LPA observed open packages of ham, cheese, Ect, and vegetables that are dried inside the refrigerator.
· At 1:00PM LPA observed mouse or rat droppings underneath the sink cabinet.
· At 1:10PM LPA observed prescribe medication unlocked in the refrigerator, kitchen cabinet, and bathroom.
· At 1:25PM LPA observed emergency exit is being blocked in resident room.
· At 1:35PM LPA observed unlocked and located, Lysol wipes in the kitchen area, and bleach underneath the sink.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


Exit interview conducted. A copy this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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