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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 12:31:09 PM

Substantiated


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
02/23/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240223144547
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:
10:45 AM
MET WITH:Angela ChicasTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Licensee did not provide POA a copy of the signed Admission Agreement
INVESTIGATION FINDINGS:
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On 4/12/24 at approximately 12pm Licensing Programm Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings related to the above listed allegations. LPA Jensen met with Angela Chicas and explained the purpose of today's visit.
On 3/1/24 LPA Jensen interviewed the Licensee by telephone. The Licensee, Bonaire Yepez, confirmed that she did not provide a copy of the Admission Agreement to the resident's Power of Attorney upon signing however she was willing to provide a copy of the agreement at any time after admission upon request. The Licensee/Administrator also stated that she was not aware that providing a copy of the admission agreement was a regulatory requirement. Based on the interview with the Licensee/Administrator the allegation of "Licensee did not provide POA a copy of the signed Admission Agreement" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited pursuant to the the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct Deficienices may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided.
Substantiated
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)
Page: 1 of 2
Control Number 27-AS-20240223144547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2024
Section Cited
CCR
87507(e)
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Admission Agreements
The licensee shall provide a copy of the signed and dated current admission agreemen... immediately upon signing the admission agreement or modification. This requirement was not met based on:
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The Licensee agrees to sign an attestation that CCR 87507 has been read, understood and will be complied with in it's entirety and will email teh attestation to maja.jensen@dss.ca.gov by the Plan of Correction due date.
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the Licensee's own admission that a signed copy was not provided to the resident's responsible party. This poses a potential health, safety and personal rights risk to residents in care.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

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

DATE: 04/12/2024
LIC9099 (FAS) - (06/04)
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