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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430708594
Report Date: 02/11/2026
Date Signed: 02/11/2026 12:20:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2026 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20260203142643
FACILITY NAME:BONHOMIE III - LENA DRIVEFACILITY NUMBER:
430708594
ADMINISTRATOR:ROMULDEZ, JONAFACILITY TYPE:
740
ADDRESS:2795 LENA DRIVETELEPHONE:
(408) 448-0905
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 5DATE:
02/11/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gladys SmartTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not keep resident’s personal information confidential.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced initial complaint investigation visit and met with Gladys Smart, Administrator (ADM).

During visit, LPA obtained copies of resident records, interviewed ADM and staff S1, and observed resident R1 and R1's bedroom. LPA also observed R2's bedroom.

During visit, LPA Marrufo observed that resident R1's bedroom had a posting on a wall near R1's bed. The posting had the name of R1's hospice agency and the hospice agency's telephone number.

LPA toured the facility and also observed R2's bedroom had a posting with R2's hospice name and telephone number posted near R2's bed. See LIC9099-C page for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 26-AS-20260203142643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BONHOMIE III - LENA DRIVE
FACILITY NUMBER: 430708594
VISIT DATE: 02/11/2026
NARRATIVE
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R1's resident record contained an Advanced Health Care Directive identifying R1's family member, FM1, as R1's medical Power of Attorney (POA).

During visit, S1 stated that R1's family member, FM2, had visited R1. S1 stated FM2 wanted to have R1 taken to the hospital, but S1 stated to have told FM2 that R1 is on hospice and only the hospice agency can decide to take R1 to the hospital. S1 stated to have provided FM2 with the name of R1's hospice agency and the hospice agency's telephone number. S1 stated the name and phone number of R1's hospice agency were shown on the posting on the wall near R1's bed. S1 stated to have sent a text to FM1 on 02/01/2026 around 11:00 AM telling FM1 that S1 had given FM2 the name and telephone number of R1's hospice agency.

Based on records review, interviews and observations, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated.

See LIC9099-D for a deficiency cited as per the California Code of Regulations, Title 22.

This report was reviewed with Administrator Gladys Smart and a copy of this report and appeal rights were provided.

Page 2 of 2.

END REPORT
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20260203142643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BONHOMIE III - LENA DRIVE
FACILITY NUMBER: 430708594
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2026
Section Cited
CCR
87468.2(a)(2)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities
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Licensee agrees to submit a plan of correction to the department by 02/12/2026 stating how the licensee will ensure that all residents' records and personal information remain confidential, including removing personal information
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for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by: Licensee did not ensure that residents R1 and R2's hospice agency information remained confidential, which poses an immediate safety risk to residents in care.
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from view in residents' bedrooms and training staff on not giving away confidential information to unauthorized persons. Once training is complete, the licensee agrees to submit copies of training records, including names of staff trained, training dates, training topic(s), and names and qualifications of trainers to the department.
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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.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3