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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 09/09/2021
Date Signed: 09/11/2021 12:37:31 PM

Document Has Been Signed on 09/11/2021 12:37 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BONNIE'S CARE HOMEFACILITY NUMBER:
502701087
ADMINISTRATOR:YEPEZ, BONAIREFACILITY TYPE:
740
ADDRESS:2608 VENEMAN AVENUETELEPHONE:
(209) 272-4444
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: DATE:
09/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:BONAIRE YEPEZ TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA arrived and was granted entry to the facility by Applicant Bonaire Yepez. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 7/6/2021 for a capacity of six non-ambulatory residents.

LPA Hurt observed the following:
Structure:
Facility is a one story house with 3 resident bedrooms, 1 bathrooms, family / living room, dining area and kitchen. The fourth and fifth bedrooms in the home are designated for licensee and family to reside. There is a 2 car garage attached in front of home. The resident bedrooms will accommodate residents' furnishings.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
Bedrooms #1-3 will accommodate 6 non-ambulatory residents
Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in/shower.
Linens and Hygiene Supplies:
Adequate supply of linens is stored in hallway closet.
Emergency Phone Numbers, Exit Plan, and Sample Menu:
Will be posted and readily available for review in the living room.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087
VISIT DATE: 09/09/2021
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Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables would be stored in the kitchen and pantry.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems were hardwired and found operational.
Fire Extinguisher:
2 Fully charged and stored by the kitchen and in the hallway.
Fire Clearance:
Approved on 07/30/2021
Appliances:
Electric four burner stove with oven, refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer are located in the laundry room next to kitchen and were clean and noted to be operational.
Toxins:
Will be locked and stored under kitchen sink.
Water Temperature:
Tested and recorded at 130 degrees (out of regulation range)
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored next to kitchen. Medication will be stored and locked in kitchen.
Resident and Staff Files:
Records will be kept in medication cabinet.
Reading Material, Games, Equipment, & Materials:
The facility has materials that commensurate with their plan of operation.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087
VISIT DATE: 09/09/2021
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The following items need to be corrected before the facility can become licensed:
.Hot water will be adjusted to 105 - 120 degrees F.

Applicant will notify LPA of completion of the above items.

The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Unit.

Applicant was reminded of the statute that requires notification to Licensing Program Analyst within 5 business days of admitting the first resident. This notification may be done by phone, mail, email or fax.

An exit interview was conducted and a copy of this report was provided at the time of visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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