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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202376
Report Date: 08/08/2025
Date Signed: 08/13/2025 09:56:26 AM

Document Has Been Signed on 08/13/2025 09:56 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:
08/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Administrator Mercelo GarciaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Mercelo Garcia. During the visit, LPA observed 4 residents and 2 staff. LPA explained the purpose of the visit. (This report is being amended to add additional information.)

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the home, LPA noted there was "hook & eye", metal latch outside the living room door, leading towards the outside. Note, this facility is licensed to have 3 non-ambulatory on the first floor and 1 bedridden in bedroom #3. The exit located in the living room, and adjacent to bedroom #3 is the only exit that has a ramp. LPA asked ADM why this latch was on the outside of the door. ADM asked staff S1, who stated the latch was put there because there used to be a resident who wanted to go outside a lot. ADM stated this resident no longer lives in the facility. ADM removed the metal latch during visit.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 118 degrees F in resident bathrooms.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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
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: 08/08/2025
NARRATIVE
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LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. Residents R1, R2 and R3 did not have multiple medications listed on the centrally stored medication record. Note Resident R1, R2 and R3's centrally stored medication record did not have any medications listed with a fill date of 2025.

Fire extinguisher was serviced in November 4, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. The facility's emergency and disaster plan was last reviewed by ADM on September 21, 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility conducted drills on the following dates: June 15, 2024, September 21, 2024, April 13, 2025, and July 10, 2025.

LPA discussed with ADM that drills conducted must occur at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, And Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

LPA Provided ADM with a copy of PIN 25-05-ASC, PIN 25-08-ASC

Deficiencies and a technical Assistance is being cited during today's visit. This report was reviewed with Administrator Mercelo Garcia and a copy of the signed report was provided. Appeal rights were provided.

Page 2 Out of 2. END OF REPORT.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/08/2025 12:06 PM - It Cannot Be Edited


Created By: Manuel Monter On 08/08/2025 at 11:29 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BONNEVIE RESIDENCE AND CARE
FACILITY NUMBER: 435202376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 and interview, the licensee did not comply with the section cited above. LPA noted there was "hook & eye", metal latch outside the living room door, leading towards the outside. S1 stated the latch was put there because there used to be a resident who wanted to go outside a lot. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2025
Plan of Correction
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ADM removed the metal latch during todays visit on 08/08/2025. ADM stated he will send a letter of understanding regarding the regulation, and the importance of keeping all passageways clear of any obstructions, by POC date, August 9, 2025.
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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2025 12:06 PM - It Cannot Be Edited


Created By: Manuel Monter On 08/08/2025 at 11:29 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BONNEVIE RESIDENCE AND CARE
FACILITY NUMBER: 435202376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The facility conducted drills on the following dates: June 15, 2024, September 21, 2024, April 13, 2025, and July 10, 2025. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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ADM stated he will send a written plan of action on how he will ensure drills are conducted quarterly, with different scenarios, taking into account different emergency scenarios. ADM stated Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. ADM stated he will send LPA the written plan by POC date, August 15, 2025.
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above. LPA reviewed 3 resident medications and centrally stored medication records. Residents R1, R2 and R3 did not have multiple medications listed on the centrally stored medication record. Resident R1, R2 and R3's centrally stored medication record did not have any medications listed with a fill date of 2025. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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 ADM stated he will send a written plan of action on how he will ensure residents centrally stored medication records will be complete with the following information: Name of resident, name of the prescribing physician, drug name, strength and quantity.The date filled, prescription number and the name of the issuing pharmacy, Instructions, and start date. ADM stated he will send LPA a copy of R1-R4's completed centrally stored medication record and the plan of action by 8/15/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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