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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002715
Report Date: 08/27/2025
Date Signed: 08/27/2025 05:12:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250606105519
FACILITY NAME:BONHURST ASSISTED LIVING. CORP (HOUSE II)FACILITY NUMBER:
455002715
ADMINISTRATOR:SKEVIG,ANGELINA MANDRIAFACILITY TYPE:
740
ADDRESS:5957 BEAUMONT COURTTELEPHONE:
(530) 244-8458
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 3DATE:
08/27/2025
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Administrator, Angelina Skevig.TIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Facility did not issue the refund for June 2025.
INVESTIGATION FINDINGS:
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On 08-27-25, Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 06-06-25. LPA Benson met with Administrator, Angelina Skevig and explained the purpose of the visit.

During the interview process staff were interviewed and documents were reviewed. The following documents were received and reviewed: resident admission agreement, R1’s Medical Administrative Record (MAR), R1’s physicians report (LIC 602), Hospice records and Staff roster with phone numbers.


Continued on LIC9099C and LIC9099D.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Sarah Benson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 59-AS-20250606105519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONHURST ASSISTED LIVING. CORP (HOUSE II)
FACILITY NUMBER: 455002715
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
11/27/2025
Section Cited
HSC
1569.652(c)
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1569.652 Termination of admission agreement. ...(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
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Administrator will refund the resident representive.
Administrator will have admission agreement reviewed.
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This requirement is not met as evidenced by:
The responsible party gave a 30 day notice to vacate on 5-22-25. The residents belongings were removed on 5-30-25. The residents paid fees were not returned within the 15 day time period. Which poses a potential health, safety or personal rights risk to persons in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Sarah Benson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250606105519

FACILITY NAME:BONHURST ASSISTED LIVING. CORP (HOUSE II)FACILITY NUMBER:
455002715
ADMINISTRATOR:SKEVIG,ANGELINA MANDRIAFACILITY TYPE:
740
ADDRESS:5957 BEAUMONT COURTTELEPHONE:
(530) 244-8458
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: DATE:
08/27/2025
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Administrator, Angelina Skevig.TIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Facility did not manage resident's medications per thier health needs.
Facility was not following resident's diet orders.
INVESTIGATION FINDINGS:
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Facility did not manage resident’s medications per their health needs.
LPA reviewed resident records and conducted extensive interviews.
Staff stated I keep a stock of as needed medications and no excessive medications. Staff stated R1s medication was administered as prescribed by the physician. Staff reported all medication administration was carefully documented on the Medication Administration Records (MAR).
During the medication administration record review, LPA Benson found all medication records documented and accurate. Hospice record review revealed R1 is kept comfortable.
Facility was not following resident's diet orders.
During record review it was discovered R1s physician diet orders were noted as mechanical soft, may puree if needed, thicken liquids to at nectar thickness. It was reported a nurse observed scrambled eggs in R1s mouth. During the Hospice record review LPA Benson found no note of finding eggs in R1s mouth. Staff stated they had not given R1 eggs, we served pureed food from the morning menu, often we served oatmeal. Staff stated R1 also received a protein shake every morning as part of her nutritional support.
Based on the interviews conducted the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Sarah Benson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 59-AS-20250606105519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BONHURST ASSISTED LIVING. CORP (HOUSE II)
FACILITY NUMBER: 455002715
VISIT DATE: 08/27/2025
NARRATIVE
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Facility did not issue the refund for June 2025.

LPA reviewed resident records and conducted extensive interviews. Record review revealed a 30-day notice to vacate the facility was delivered on 5-22-25. Review of the admission agreement reveal a notice stating "This agreement remains in effect after the death of the resident: payment is owed until the following conditions are met: Balance is paid and the room is vacated, "Hospice Care". The Admission Policy states, "I also understand that Bonhurst Assisted Living Corporation will no longer provide any refund for a Direct Hospice Admission in case of death for any circumstances of her stay in the facility". LPA was able to determine R1 was moved from the facility with personal belongings on 5-30-25 and no refund was issued. In addition, Health and Safety Code §1569.652 states facilities are required to refund responsible party within 15 days once their personal belongings have been removed.


Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.


Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Sarah Benson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4