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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 10/19/2022
Date Signed: 10/21/2022 01:17:23 PM

Document Has Been Signed on 10/21/2022 01:17 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: 4DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bonaire YepezTIME COMPLETED:
01:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 10/19/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff person, Gabriela Chicas, who was reuquested by this LPA to go ahead and contact the facility designated Administrator Bonaire Yepez to inform her that CCL was present at this time. The facility designated Administrator arrived later on to this facility while this LPA was conducting the annual visit and was briefly interviewed.
This facility is licensed to accept and retain up to 6 residents at any given time.
Current census was 4 residents. Tour of this facility was conducted.
It was learned that this facility is cleared to accept and retain up to (6) residents under hospice care. It was learned that there were (4) residents under hospice care at this time.
A tour of the facility resident rooms was conducted. Resident furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Resident restrooms were toured and observed to be able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees at this time.
Kitchen area was toured.
Medication cabinets were observed to be present in the hallway area. Policies and procedures were discussed with facility staff in terms of dispensing, documenting, and overall administration of resident medications.
First aid kits were observed to be present and contained all of the necessary components at this time.
Policies and procedures were discussed in relation to narcotics and medications that required a separate count and documentation by incoming staff and outgoing staff. A review was conducted in regards to this documentation of the resident narcotics.
Living area, dining area, and all other areas intended for resident use were toured and observed to be in compliance at this time.
Fire extinguisher, located in the living area, was observed to have been annually inspected by the local fire
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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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: 10/19/2022
NARRATIVE
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extinguisher company, Jorgensen & Co, at this time.
Laundry area was toured. Chemicals, detergents, and bleaches were observed to be locked and made inaccessible to the residents at this time.
A review of the food supply was conducted to make sure that there was a sufficient amount of 2-day perishable and 7-day nonperishable quantities at all times.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 rules and regulations, Health and Safety Code.

The appeal rights were printed and a copy was given to the facility designated staff person at this time.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2022 01:17 PM - It Cannot Be Edited


Created By: Charlie Yang On 10/19/2022 at 01:16 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since the backyard will need to be cleaned up and the debris/unused items will need to be removed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2022
Plan of Correction
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Facility designated staff member stated that all unused items in the backyard will be removed and discarded. A statement of correction will be submitted. along with photos of the cleared/cleaned backyard area, into CCL for review by this LPA by the due date of 10/26/2022.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that several bedroom and common room window screens were either ripped, torn, or in need of repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2022
Plan of Correction
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Facility designated staff member stated that all facility window screens will be reviewed and repaired as needed. A statement of correction will be completed, along with photos of all updated window screens, will be submitted into CCL for review by this LPA by the due date of 10/26/2022.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022


LIC809 (FAS) - (06/04)
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