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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:09:55 PM

Document Has Been Signed on 09/04/2024 03:09 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: 5DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Maria AraizaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 9/4/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual inspection. LPA Jensen met with care provider Maria Araiza and explained the purpose of today's visit. Maria Araiza advised LPA Jensen that she has submitted an application for licensure in anticpation of a change of ownership. Licensee Bonnaire Yepez has confirmed that she is in the process of transferring the licensure.

LPA Jensen toured the grounds and found them to be well maintained with all paths clear of obstruction. LPA Jensen toured the interior and observed there to be adequate lighting and furnishings. There are currently 5 residents with 4 residents in the home and 1 resident in the hospital. The smoke detectors were determined to be in good working order. There are no carbon monoxide detectors in the home. LPA Jensen toured the kitchen and observed insufficient perishable food and non-perishable food. The perishable food was restocked in the presence of LPA Jensen and non-perishable food was ordered on line in the presence of the LPA to be delivered tomorrow. The fire extinguisher was last serviced in 2022 and was out of compliance. A new fire extinguisher was purchased and delivered during the course of this visit. The smoke detectors were observed to be in working order. There are no carbon monoxide detectors according to the care provider and LPA Jensen did not observe any.

LPA Jensen Jensen reviewed the Medication Administration Record (MAR) for resident 1 (R1) and saw an ace inhibitor medication listed as a PRN. LPA Jensen checked the label and saw the medication was not a PRN. The medication came in a bubble pack and appeared to be administered on a daily however the number of pills remaining did not align with the dates listed on the Centrally Stored Medication and Destruction Record.

The laundry room was inspected and cleaning products were observed that were accessible to residents in care. Various grooming supplies such shampoos, cleansers, wound treatment was also observed in 2 bedrooms to be accessible to residents in care.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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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: 09/04/2024
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LPA Jensen conducted an interview with resident 2 (R2) It was learned that R2 has a wheel chair however the wheel chair does not fit through the bedroom door. LPA Jensen also observed that R2 is in need of podiatry care (photo taken). During the course of this visit a home health/social worker (SW1) came to visit R2. LPA Jensen asked SW1 to assist in arranging podiatry care for R2 and to address the need for R2 to have the ability to use her wheel chair. LPA Jensen observed 2 different topical medications in a resident closet for residents that are deceased.

LPA reviewed the resident file for R2. The LIC had incomplete sections and a large portion of it was filled out by the resident. The resident was charged a rent increase for a change in condition but there was no change to the needs and service plan. The increase in rate was also not itemized. R2 uses a BIPAP machine and there is no mention of the BIPAP machine on the resident appraisal or needs and service plan.

This annual inspection will require a continuation. Deficiencies are being cited and a civil penalty is being assessed.

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

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
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Page: 2 of 4
Document Has Been Signed on 09/04/2024 03:09 PM - It Cannot Be Edited


Created By: Maja Jensen On 09/04/2024 at 02:26 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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2024
Section Cited
CCR
87203

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Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by:
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The Licensee has replaced the fire extinguisher and will purchase and install carbon monoxide detectors by POC due date.
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Based on LPA Jensen's observation and care providers statement that the facility does not have carbon monoxide detectors. This poses an immediate risk to the health safety and personal rights of residents in care
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Type A
09/04/2024
Section Cited
CCR87555(b)(26)

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Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by:

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Maria Araiza purchased food and had it delivered in the repsence of the LPA. No further plan of correction is required at this time.
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Based on LPA Jensen's observations the facility did not have 2 days worth of perishable foord or 7 days worth of non-perishable food
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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: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/04/2024 03:09 PM - It Cannot Be Edited


Created By: Maja Jensen On 09/04/2024 at 02:36 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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2024
Section Cited
CCR
80072(a)(2)

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Personal Rights
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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LPA Jensen asked a home health aid/social worker assigned to the resident to assist with residents wheel chair not fitting through doorway during the course of the visit. Licensee will follow up to advise of outcome by 9/9/24.
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Based on an interview with R2 and LPA Jensen's measurement of the bedroom doorway, R2 cannot exit the bedroom in her wheelchair. 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: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024


LIC809 (FAS) - (06/04)
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