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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 10/18/2021
Date Signed: 10/18/2021 12:51:08 PM

Document Has Been Signed on 10/18/2021 12:51 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: 2DATE:
10/18/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bonaire Yepez , AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sarah Hurt arrived unannounced to conduct a post licensing visit and explained purpose of visit. LPA met with Administrator Bonaire Yepez. There are currently 2 residents residing at the facility at this time, and 1 of those residents is on hospice. LPA toured and inspected the interior/exterior of the facility including the common living spaces. The facility is licensed for 6 non-ambulatory, with hospice waiver for six. There is 3 resident bedrooms, 3 bathrooms, kitchen and laundry area. Food supply is adequate for 2-day perishable and 7-day nonperishable. Sharps and toxins were locked. Hot water temperature measures at 112 degrees F. Bedrooms have required furniture and sufficient lighting. Bathrooms are equipped with necessary grab bars and non-skid mats. LPA toured the backyard, all exits are accessible and unlocked. There are no bodies of water present.

LPA observed centrally stored medications are locked. Garage has extra refrigerator/freezer with food. LPA observed an adequate amount of linens and found the first aid kit to be complete.

Smoke alarms were checked and in good working order and facility is free of odors, clean and in good repair. Fire extinguishers (06/10/2021), smoke detectors, and carbon monoxide detectors are in compliance. First aid kit is complete.

Administrator Bonaire provided staff records. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Administrator Bonaire Yepez holds a certificate that expires 06/23/2022.

Licensee has proof of liability insurance (expires 10/06/2022.)



No deficiencies were cited during today's inspection. Exit interview and copy of report given to Administrator Bonaire Yepez.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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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