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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701087
Report Date: 01/19/2023
Date Signed: 02/14/2023 03:48:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2022 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221013091852
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: 6DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gabriela ChicasTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not properly trained

Staff are not providing adequate care and supervision of resident

Staff are restricting visitation to resident
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 01/19/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff person, Gabriela Chicas, who was briefly interviewed. This LPA requested that the facility staff person go ahead and contact the facility designated Administrator, Bonaire Yepez, to inform her that CCL was present at this time. The facility designated Administrator was notified but was unable to come to the facility at the time of this LPA's visit. Facility staff person, Gabriela Chicas, was authorized to sign all documents by the facility Licensee at this time.
Current census was 6 residents.
The purpose of this visit was to deliver the findings of this investigation unto the facility and its representative.
Based on interviews conducted during the course of this investigation it was learned that R1 was admitted into this facility back in August 2022. It was learned that R1 was left in this facility without proper supervision by any properly trained facility staff on one instance.
Trained facility staff did not arrive until some time later to relieve the individual who was present at that time.
It was also learned that R1 was left unattended, during this incident, and was attempting to eat without any
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
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 27-AS-20221013091852
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/19/2023
NARRATIVE
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success or facility assistance.
This facility was found to deficient since it did not properly make sure that staff were always sufficient in numbers and properly trained as outlined in Title 22 Rules and Regulations.
This facility was also found to be deficient since it did not properly make sure that facility residents' basic care needs were always met and fulfilled by sufficient facility care staff.
Based on observations, it was learned that a posting was put up near the entry way of this facility. The intent of this posting was to alter the visiting hours for family members, friends, and responsible parties and deviated from the posted hours in the Admission Agreement (LIC 604) that were already set forth. It was observed from the posting that visitors had to call and inform the facility staff prior to their intended visitation.
This facility was found to be deficient as evidenced by the posting of altered visiting hours and policies which contradicted the visiting policies already set forth in the facility program and Admission Agreement (LIC 604).

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

A civil penalty in the amount of $100 has been issued to the facility at this time per the LIC 421BG.

Appeal rights were printed and a copy was given to the facility staff person, Gabriela Chicas, who was present at this time.

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

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20221013091852
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited
HSC
87411(c)
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Personnel Requirements-General
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
This facility was found to be deficient as evidenced by the presence of facility
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Facility representative stated that facility staff persons should be trained and certified as such in order to adequately provide care and supervision to the residents.
A statement of correction, along with proof of training for no less than (1) hour in duration, will be completed and submitted into CCL by the due date of 01/26/2023.
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personnel who were not properly trained to adequately provide care and supervision to the residents.
This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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This training requirement should encompass the importance of required training topics and adequate care and supervision. Proof of training should include the name of the trainer, topics that were covered, and list of the participants.
Type A
01/26/2023
Section Cited
CCR
87464(f)(4)
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Basic Services
Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
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Facility representative stated that facility staff persons should be trained and certified as such in order to adequately provide care and supervision to the residents.
A statement of correction, along with proof of training for no less than (1) hour in duration, will be completed and submitted into CCL by the due date of 01/26/2023.
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This facility was found to be deficient as evidenced in that it did not properly make sure that facility residents' basic care needs were always met and fulfilled by sufficient facility care staff.
This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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This training requirement should encompass the importance of required training topics and providing proper care and supervision at all times to the residents. Proof of training should include the name of the trainer, topics that were covered, and list of the participants.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20221013091852
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2023
Section Cited
CCR
87468.1(a)(11)
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Personal Rights of Residents in all Facilities
To have their visitors, including Ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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Facility representative stated that the posting will be removed and this facility will only follow the visiting policies already set forth in the program and Admission Agreement (LIC 604). A statement of correction, along with removal of the posting, will be completed and submitted into CCL by the due date of 01/26/2023.
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This facility was found to be deficient as evidenced by the posting of altered visiting hours and policies which contradicted the visiting policies already set forth in the facility program and Admission Agreement (LIC 604).
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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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4