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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502701087
Report Date:
09/11/2024
Date Signed:
09/11/2024 12:33:03 PM
Document Has Been Signed on
09/11/2024 12:33 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 HOME
FACILITY NUMBER:
502701087
ADMINISTRATOR/
DIRECTOR:
YEPEZ, BONAIRE
FACILITY TYPE:
740
ADDRESS:
2608 VENEMAN AVENUE
TELEPHONE:
(209) 248-7663
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95356
CAPACITY:
6
CENSUS:
5
DATE:
09/11/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:
Maria Araiza
TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 9/11/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a Plan of Correction visit. LPA Jensen met with Maria Araiza and explained the purpose of today's visit.
LPA Jensen followed up on a deficiency for a personal rights violation observed on 9/4/24. LPA Jensen interviewed Resident 1 (R1) who confirmed that she has a new wheel chair that fits through the door. R1 also has a podiatry appointment scheduled.
The plan of correction has been cleared. 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:
09/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2024
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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