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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701087
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:05:26 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240404104236
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: 3DATE:
04/12/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Angela ChicasTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide residents authorized person copies of resident's records
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/12/24 at approximately 10:45 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unanounced to open a complaint investigation in to the above listed allegation. LPA Jensen met with Angela Chicas who advised the Licensee/Administrator is out of town and unanavailble. Angela Chicas advised she is the designee in the Administrator's absence.

LPA requested the records for Resident 1 (R1). LPA Jensen was only provided a hospice binder. LPA Jensen spoke to the Licensee by telephone and she confirmed that only the hospice records are available and the attorney was sent what records were available. Based on an interview with the Licensee all available records sent upon request and the "staff did not provide resident's authorized person copies of resident's records is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preonderance of evidence does not prove it. A seperate case management will be conducted for a lack of required records. An exit interview was conducted and a copy of this report and appeal rights were provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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