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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202376
Report Date: 12/19/2024
Date Signed: 12/19/2024 02:40:32 PM

Document Has Been Signed on 12/19/2024 02:40 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:BONNEVIE RESIDENCE AND CAREFACILITY NUMBER:
435202376
ADMINISTRATOR/
DIRECTOR:
MERCLO GARCIAFACILITY TYPE:
740
ADDRESS:555A MC LAUGHLIN AVENUETELEPHONE:
(408) 931-6077
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6CENSUS: 5DATE:
12/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Merclo GarciaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPAs) Marcela Yanez and Simi Rai conducted an unannounced case management visit to follow up on the Type A and Type B deficiencies cited on 10/31/2024. LPAs met with Administrator Merclo Garcia and stated the purpose of today's visit. LPA Yanez observed 4 staff and 4 residents in the facility.

During visit, LPA Yanez inspected the kitchen area. LPA Yanez observed sharps, such as knives, and toxic chemicals locked in cabinet and inaccessible to residents. LPA Yanez observed medications were in the locked cabinet and inaccessible to residents. During visit LPA tested the hot water temperature with thermometer at 110.8 degrees F.
During visit LPA reviewed Admission agreement for Residents R1-R5 to be signed by the Administrator and the resident. During visit LPA observed windows clean and clear of debris and cob webs and Screens were in good repair in Resident bedrooms. LPAs observed 2 day perishable and 7 day non perishable food supply. LPAs observed 7 day non perishable food to be a variety of vegetables and protein.
During visit, LPA Yanez provided letter of the Deficiency Citations cleared.

Administrator stated that the Fire Clearance is still pending further review. ADM stated the Fire Marshall will call back with further details.

In order to exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves, LPA Rai discussed with ADM Merclo Garcia for Administrator to be available and present at the facility 20 hours a week, Monday through Friday 8:00am - 5:00pm. ADM updated LIC 500 which reflect the hours of ADM present at the facility during Monday - Friday and was submitted to LPA Rai.
No deficiencies were cited at this time as per California Code of Regulations, Title 22.This report was reviewed with Administrator Merclo Garcia and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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