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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202959
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:22:19 PM

Document Has Been Signed on 03/12/2025 04:22 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:BONITA SPRINGS SENIOR LIVINGFACILITY NUMBER:
435202959
ADMINISTRATOR/
DIRECTOR:		CERA, DULCEFACILITY TYPE:
740
ADDRESS:1818 SCOTT BLVDTELEPHONE:
(408) 380-4036
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 32CENSUS: 0DATE:
03/12/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Syeda Omer, OwnerTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On March 12, 2025 at 2:00 PM, Licensing Program Analysts (LPA) Kenneth Madrigal and Steve Chang conducted a Pre-licensing visit. LPAs met with Syeda Omer, Owner and Dulce Cera, Administrator (ADM) and was granted access to the facility.

LPAs toured the facility inside and out with the ADM and the owner. On the first floor, there are 11 resident bedrooms with each room having its own bathroom, one medication room, lobby area, recreation activity room, shower room, bathrooms, kitchen area, dining room, office, lounge, two small bathrooms, one accessible bathrooms, and 5 emergency exits. On the second floor, there are 5 resident rooms, and two emergency exits. LPAs observed the rights rights, resident council, theft policy, emergency disaster plan, and other forms that are viewed for display at the facility hallways. LPAs observed the areas for storing the locked medication and knifes area. ADM stated that there no will be "live in staff", and there are no staff bedrooms. There is a fire alarm and carbon monoxide system that connects to all the fire alarms in the facility. LPAs observed a storage room in the backyard that the Owner stated that she does not have access to that space and does not own that property as the Owner is leasing the building, she does not have ownership of that storage room for the next 1 year to 1 year and half per the owner's contract.

The current submitted floor plan to CAB Analyst and the physical plant on today's visit has minor differences. The designated rooms in the floor plan does not match the physical plant. ADM provided an updated floor sketch plan to LPAs. LPAs advised to submit this updated sketch floor to CAB Analyst.

The current phone number on Field Automation System (FAS) is no longer in service. ADM stated that they have purchased a new phone line for the facility which is (669) 242 - 7150 and the facility is now using the new phone number and it was tested by ADM and LPAs. The fridge temperature was 40 degrees F, the freezer temperature was recorded at 0 degrees F, and the water temperature is 120 degrees F. The fire extinguisher was last serviced on June 10, 2024.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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 2
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: BONITA SPRINGS SENIOR LIVING
FACILITY NUMBER: 435202959
VISIT DATE: 03/12/2025
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Component III was presented to the ADM and the owner.

LPAs provided a resource, Technical Support Program (TSP) with a URL link to ADM and the owner of the facility.

An exit interview was conducted with ADM and the owner and a copy of this report was provided to them.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2