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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701087
Report Date: 12/10/2024
Date Signed: 12/10/2024 12:32:06 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
12/06/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20241206152840
FACILITY NAME:BONNIE'S CARE HOMEFACILITY NUMBER:
502701087
ADMINISTRATOR:LACY VINCENTFACILITY TYPE:
740
ADDRESS:2608 VENEMAN AVENUETELEPHONE:
(209) 248-7663
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 4DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria AraizaTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not ensure residents personal possessions were safely secured
INVESTIGATION FINDINGS:
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On 12/10/2 Licensig Program Analyst (LPA) Maja Jensen arriived at facility to open a complaint investigation in to the above liisted allegations. LPA Jensen met with Maria Araiza and explained the purpose of today's visit.

LPA asked when the Administrator is present. Maria advised that she come in on weekends. LPA Jensen requested copies of documents from the file of resident file for resident 1 (R1). LPA Jensen was advised that the copier is not working this time. LPA Jensen reviewed the file and observed the client//resident personal property and valuables (LIC 621) to be blank. LPA Jensen asked Maria what the facility policy is regarding safeguarding personal property. Maria stated that items are labeled with the resident's name and logged. LPA Jensen asked if R1 came to the facility with any personal belongings. Maria replied that R1 came with the clothing that he was wearing and then his family also brought items.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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 4
Control Number 27-AS-20241206152840
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
VISIT DATE: 12/10/2024
NARRATIVE
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Based on LPA Jensen's observation of a blank LIC 621 and the interview conducted with Maria Araiza the allegation of Staff did not ensure residents personal possessions were safely secured" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. In this instance the facility did not follow it's own policies for safeguarding resident valuables or theft and loss prevention.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6.

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: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20241206152840
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: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2024
Section Cited
CCR
87217(b)
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Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirerment was not met as evidenced by:
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An attestation will be sent by email to the Department stating that Maria Araiza will personally label and maintain written logs of resident property effective immmediately. This Plan of Corretion is based on facility staff request. No further action required.
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Based on LPA Jensen's interview with staff and observation of a blank LIC 621 the faciity did not follow it's own policies for safeguarding resident valuables.
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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: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4