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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 01:35:22 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/30/2022 01:35 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:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Direct Care Staff Leticia AldanaTIME COMPLETED:
12:04 PM
NARRATIVE
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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.

During infection control/annual visit LPA observed the following:
Light bulbs in room #1 missing from light sockets. Light switches in facility non-functioning. Room #4 does not have sufficient lighting and making noise. Light bulbs need replacement in room and in restroom. Clutter observed along fence (boxes, bed frame, boards and window frame). Left side fence does not properly open/close and/or lock. Torn and saturated recliner along pool fence. Right side gate latch rusted and does not properly close/open and/or latch. Pool has been emptied but has water filling in deep end that is dirty. Garage observed with clutter and debris.

Deficiency cited on 809D.

Exit interview completed with Direct Care Staff, Leticia Aldana. A copy of this report and appeal rights 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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Document Has Been Signed on 12/30/2022 01:35 PM - It Cannot Be Edited


Created By: Mary Garza On 12/28/2022 at 11:19 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: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee to complete training with all staff on regulations cited and to provide sign in sheet and training materials to CCL by POC date. Licensee to provide proof of corrections upon completion and no later than 1/10/23
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This requirement was not met as evidence by: LPA observation of the following; Light switches in facility non-functioning. Clutter observed along fence (boxes, bed frame, boards and window frame, recliner chair). Side fences do not properly open/close and/or lock/latch. Emptied pool has dirty water in deep end. Garage observed with clutter and debris.
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Type B
01/06/2023
Section Cited
CCR87303(d)

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87303 Maintenance and Operation (d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.
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Licensee to complete training with all staff on regulations cited and to provide sign in sheet and training materials to CCL by POC date. Licensee to provide proof of corrections upon completion and no later than 1/10/23
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This requirement was not met as evidence by: LPA observation of the following; Light switches in facility non-functioning, Light bulbs in room #1 missing from light sockets. Room #4 does not have sufficient lighting and making noise. Light bulbs need replacement in room and in restroom.
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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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022


LIC809 (FAS) - (06/04)
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