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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202778
Report Date: 09/09/2021
Date Signed: 09/10/2021 09:57:57 AM

Document Has Been Signed on 09/10/2021 09:57 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BONITA SPRINGS SENIOR CAREFACILITY NUMBER:
355202778
ADMINISTRATOR:IRENE MENDOZAFACILITY TYPE:
740
ADDRESS:1257 STEINBECK DRIVETELEPHONE:
(408) 679-0011
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 6CENSUS: 5DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Karla Jenkins, Irene MendozaTIME COMPLETED:
03:15 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, Steve Nguyen, conducted an unannounced annual inspection with Administrator, Irene Mendoza.

LPA toured facility inside and out. LPA observed: Covid signs are present; however, sink areas missing hand washing signs, emergency contact for residents were up to date, facility screening protocols were not in effect and will be rectified by AD with training, hand sanitizing station were available throughout facility, medicine cabinet were observed to be locked, paper towers are in use but missing in some areas and will be addressed by AD, all rooms in facility are single occupancy except for one room, which is cohort, and physical distancing will be practiced, and PPE training will conducted by AD on 9/9/2021 and 9/10/2021.

No citation was issued at this time.

LPA went over report findings with Administrator for review and a copy was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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 1