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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 09/07/2023
Date Signed: 09/07/2023 12:28:02 PM

Document Has Been Signed on 09/07/2023 12:28 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
SACRAMENTO AC/SC, 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: 5DATE:
09/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bonnie Yepez TIME COMPLETED:
12:30 PM
NARRATIVE
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On 09/07/2023, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced case management visit to this facility. LPA identified herself to the staff, stated the purpose of the visit, and asked to speak with the Designated Facility Administrator/Licensee "Bonnie" Yepez. The Designated Administrator/Licensee arrived within 10 minutes and a brief interview followed.

LPA and licensee reviewed and signed documents pertaining to a new fire clearance and a previous deficiency.

LPA reviewed admission packet from initial licensing and the current one in use and found discrepancies with the refund policies. The initial submission offered a prorated refund, the version that had been in use until LPA highlighted changes, stated that no refunds would be offered. The licensee understands that this change was in violation of the Health and Safety Code and will use the original application previously submitted. Any revisions made in the future will be submitted for approval prior to implementation.

LPA provided information regarding regulations pertaining to refunds as well as rate changes, as the Licensee is considering changing her rates to more accurately match the market.

No other deficiencies were observed or cited during today's visit. The above deficiency is cited on the LIC 809 D Page. As the Licensee had an appointment to attend to, she granted permission for her staff person to sign on her behalf.

A copy of this report and Appeal Rights were provided.

Exit interview conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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Document Has Been Signed on 09/07/2023 12:28 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 09/07/2023 at 11:48 AM
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: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2023
Section Cited
HSC
1569.652(c)

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Termination of admission agreement upon death of resident; ... (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..., within 15 days after the personal property is removed.
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The Licesnee shall revert back to the orignal agreement immediately and any desired changes to it (incuding rate increases) shall be submitted to the appropriate DSS branch for prior approval before being put into practice. Licensee agreed to submit an updated signed and version of the orignal
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The Licensee failed to meet this requirement when they altered their original admissions agreement to state that no refunds woud be given.
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admission agreement to kimberly.viarella@dss.ca.gov by 09/11/23 for review.

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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
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