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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202376
Report Date: 04/09/2025
Date Signed: 07/21/2025 08:16:03 AM

Document Has Been Signed on 07/21/2025 08:16 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
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: 4DATE:
04/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Merclo Garcia - AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management visit for Type A and Type B deficiencies cited on 10/31/2024 and compliance with the fire clearance. LPA met with Administrator Merclo Garcia and stated the purpose visit.

The facility is licensed to serve adults 60 years and over, 4 may be non-ambulatory and 2 ambulatory and 1 may be bedridden. LPA observed 4 out 4 residents (R,R2,R3 & R4).

LPA toured the facility inside and outside including the kitchen, dining, living room, 5 resident bedrooms and 2 staff bedrooms, restrooms, food pantry, medication cabinet, supply cabinet, exterior walkways and ramp.

LPA observed knives/sharps, medications, chemicals are not accessible to the residents, the food pantry has 7 days of non-perishable food that have a variety of vegetable and protein, organized and labeled. 2 Days of perishable food labeled and organized. The water temperature measured with a digital thermometer at 119 to 121 degree F. ADM stated that the water heater tank was recently replaced and will be monitored for a week to ensure that the water temperature stays within the regulatory standard of 105 degree F to 120 degree F.

Walkways and hallways inside the facility were free from obstruction. LPA observed audible alarms on exit doors by the living room. The exterior are maintained, with no broken screen windows, free from cobwebs, exterior ramp is maintained and free from obstructions.

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See LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BONNEVIE RESIDENCE AND CARE
FACILITY NUMBER: 435202376
VISIT DATE: 04/09/2025
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The Fire Clearance was approved by the Fire Marshall on 3/27/2025 and a copy was provided to ADM.
ADM submitted an updated LIC 500 reflecting the hours and days that ADM will be at the facility and ensure coverage during day and night time.

LPA inspected 2 resident records and 2 staff record and observed that the files were complete and updated.
The facility conducted a disaster training on 9/21/2024 and will be administered again on 4/13/2025 as stated by ADM.

No deficiencies were cited during today's visit based on California Code of Regulations, Title 22. This report was reviewed with Administrator Merclo Garcia and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
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