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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 08/01/2024
Date Signed: 08/01/2024 04:26:25 PM

Document Has Been Signed on 08/01/2024 04:26 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BONNIE'S CARE HOMEFACILITY NUMBER:
502701087
ADMINISTRATOR/
DIRECTOR:		YEPEZ, BONAIREFACILITY TYPE:
740
ADDRESS:2608 VENEMAN AVENUETELEPHONE:
(209) 248-7663
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 4DATE:
08/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Bonnie YepezTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 8/1/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management in relation to an incident report received on 7/31/24. LPA Jensen met with Angelica Chicas and explained the purpose of today's visit. Angelica Chicas called Licensee Bonaire Yepez and LPA Jensen spoke to the Licensee by telephone and explained the purpose of today's visit. The facility has a hospice waiver for 6.

An incident report was received regarding a resident in care that is on hospice. The facility notified the Department that the responsible party for resident 1 (R1) requested R1 be taken off of hospice in order to be sent to the hospital and would not be returning. LPA Jensen interviewed R1's daughter, R1's son in law and R1's close friend who all stated that R1 is being moved due to concerns at the facility surrounding sanitation and neglect. LPA Jensen inspected the facility and observed cockroaches, spiders and other unidentified insects. LPA Jensen reviewed R1's file and observed R1 was lacking a pre-placement appraisal and resident appraisal or needs and service plan. LPA Jensen reviewed the hospice care plan and observed that the care plan lacked a description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties. LPA Jensen also observed various care notes from the month of July 2024 that were signed by 2 staff members not associated to the facility. It should be noted that the licensee was provided technical assistance by email on personnel requirements, criminal background clearance and transfers on July 19, 2024.

LPA Jensen interviewed Staff 1 (S1) who advised that Staff 2 (S2) is in charge and now running the facility. LPA Jensen verified that S2 is not yet associated to the facility. LPA Jensen interviewed S2 who confirmed that she and the licensee have entered in to an agreement for a change in ownership at the beginning of July 2024. On July 19th, 2024, LPA Jensen provided technical assistance to the Licensee informing her that the Department and all residents must receive notification of any intent to sell or transfer ownership of the business. No notification was sent to date.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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 08/01/2024 04:26 PM - It Cannot Be Edited


Created By: Maja Jensen On 08/01/2024 at 03:25 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2024
Section Cited
CCR
87205

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The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement was not met as evidenced by:
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The Licensee provided notice if intent to sell during the course of this visit as well LIC 9182's for employees needing transfers. The Licensee agrees to provide all residents with notification of the intention to sell by the POC due date.
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Based on Licensee's confirmation that staff were not associated and notice of intent to sell or transfer had not been given despite technical assistance being provided by LPA Jensen on 7/19/2024. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Type B
08/08/2024
Section Cited
CCR80087(a)(1)

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Buildings and Grounds
The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by:
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The Licensee agrees to have a pest control company complete a service by POC due date and agrees to establish bi-monthly pest service.
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Based on LPA Jensen's observation of insects on the floor and in the cupboards.
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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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/01/2024 04:26 PM - It Cannot Be Edited


Created By: Maja Jensen On 08/01/2024 at 03:55 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2024
Section Cited
CCR
87506(a)

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Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility ... readily available ... to licensing agency staff. This requirement was not met as evidenced by:
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The Licensee agrees to submit an attestation that all resident files and hospice care plans are fully updated and complete by 9/2/24.
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Based on LPA Jensen's record review, R1 lacked a pre-placement appraisal, needs and service plan and complete hospice care plan. This poses an immediate risk to the health, safety and personal rights of 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.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024


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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087
VISIT DATE: 08/01/2024
NARRATIVE
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LPA Jensen provided technical assistance on hospice care and reporting requirements.

This case management will require additional time to investigate. LPA Jensen left the facility for a meal period at 12:30pm to 1:30pm.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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