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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107207113
Report Date: 12/28/2022
Date Signed: 12/30/2022 01:34:31 PM

Document Has Been Signed on 12/30/2022 01:34 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
SIERRA CASCADE AC/SC, 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: 4DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Direct Care Staff, Bertha "Leticia" AldanaTIME COMPLETED:
11:16 AM
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On 12/28/22, Licensing Program Analyst (LPA) M. Garza arrived at the facility unannounced to conduct an Infection Control/Annual Inspection. LPA contacted Administrator who stated they were unavailable. LPA was given permission to conduct visit with Direct Care Staff, Leticia Aldana. LPA stated the purpose of the visit and was allowed entry into the facility. LPA entered through a central entry point. LPA was not COVID pre-screened at entry. LPA observed a sign-in sheet and hand sanitizer.

LPA and staff completed tour of facility inside and out. Clients observed in common area and in rooms during visit. Infection control postings were not observed throughout the facility. Furniture in common areas are spaced to promote physical distancing. A supply of PPE is located in the living room in a locked tote. Hand washing postings observed at hand washing stations.

Fire Extinguisher last serviced 1/4/2022. Water temperature measured at 112 degrees F. LPA observed a first aid kit with all the required items. LPA requested the following updated forms by 1/06/22: LIC 308, LIC 309, LIC 500, LIC 610D, and LIC 9020.

No deficiencies cited during todays visit. Exit interview completed with Direct Care Staff, Leticia Aldana. A copy of this report was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
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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