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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107207113
Report Date: 11/09/2021
Date Signed: 11/12/2021 03:09:16 PM

Document Has Been Signed on 11/12/2021 03:09 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BONAVENTE HOME FOR THE ELDERLY #2FACILITY NUMBER:
107207113
ADMINISTRATOR:BONAVENTE, NIDAFACILITY TYPE:
740
ADDRESS:6097 HARRISONTELEPHONE:
(559) 313-9052
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 6DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Rose Reimer - AdministratorTIME COMPLETED:
12:20 PM
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On 11/9/2021, Licensing Program Analyst's(LPA's) D. Ayers and K. Kaur arrived at facility unannounced to conduct a Required Annual Inspection. LPA's met with Administrator Rose Reimer. Administrator Certificate is current with renewal date 6/8/2022.

LPA toured facility inside and out. All passageways and exits are clear and free from obstruction. All smoke detectors and carbon monoxide detector were functional. Facility was adequately furnished and lit. LPA's observed adequate supply of nonperishable and two day supply of perishable food stuffs. Medication was secured in locked closet and appeared to be administered properly. LPA's toured resident bedrooms and bathrooms. All bedrooms were adequately furnished and lit. Bathrooms had secure grab bars and nonskid mats. LPA's observed a sufficient supply of extra pillows and linens in hallway closets.

At 11:10 am. LPA's observed a tub of powder laundry detergent which was left on the floor in an unlocked laundry room. In the adjacent bathroom, LPA's observed two disposable razors left in an open cabinet.

Upon review of residents files, LPA's observed that two of the six residents were under the age of 60 and had the primary diagnosis of schizophrenia. A third resident was over the age of 60, but also had the primary diagnosis of schizophrenia. The administrator stated that she accepted these residents form Fresno County Behavioral Health. Additionally, according to staff and administrator, there were no planned activities for the residents.

See attached 9099D's for deficiencies cited in accordance with California Code of Regulations, Title 22. Exit interview conducted. A copy of this report and appeal rights provided via email.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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Document Has Been Signed on 11/12/2021 03:09 PM - It Cannot Be Edited


Created By: David Ayers On 11/09/2021 at 11:47 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BONAVENTE HOME FOR THE ELDERLY #2
FACILITY NUMBER: 107207113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
87219 planned Activities(a): Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.

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 in for six out of six residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2021
Plan of Correction
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Administrator to develop and submit to CCLD a schedule of planned activities which suits the residents' needs and interests.
Type B
Section Cited
CCR
87455(c)(3)(A)
87455(c)(3)(A) Acceptance and Retention Limitations (c) No resident shall be accepted or retained if any of the following apply: (3) The resident's primary need for care and supervision results from either: (A) An ongoing behavior, caused by a mental disorder, that would upset the general resident group.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview andrecord review, the licensee did not comply with the section cited above for three out of six residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2021
Plan of Correction
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Licensee and Administrator to develop an action plan for continuing compliance to this section by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Andy Xiong
LICENSING EVALUATOR NAME:David Ayers
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2021 03:09 PM - It Cannot Be Edited


Created By: David Ayers On 11/09/2021 at 12:06 PM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BONAVENTE HOME FOR THE ELDERLY #2
FACILITY NUMBER: 107207113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of two bathrooms and the laundry room, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2021
Plan of Correction
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Deficiency cleared on site during inspection.
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.
SUPERVISOR'S NAME:Andy Xiong
LICENSING EVALUATOR NAME:David Ayers
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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