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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:32:00 PM

Document Has Been Signed on 12/19/2024 03:32 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:		LACY VINCENTFACILITY TYPE:
740
ADDRESS:2608 VENEMAN AVENUETELEPHONE:
(209) 248-7663
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 5DATE:
12/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Maria AraizaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 12/19/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced. LPA Jensen met with care provider Sandra Williams and explained the purpose of today's visit. Maria Araiza arrived on the scene shortly after.

On 12/10/24 LPA Jensen reviewed a resident file for resident 1 (R1). There was no record to document the needs and services that the resident will be provided with.

Technical assistance was provided on social factors and change in administrator.

A deficiency is 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.

A 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: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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 12/19/2024 03:32 PM - It Cannot Be Edited


Created By: Maja Jensen On 12/19/2024 at 02:29 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: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2025
Section Cited
CCR
87467(a)

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Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any...
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The Licensee agrees to create a new needs and service plan template and to send revised needs and service plans for all residents to the Department by the POC due date.
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to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This requirement was not met as evidenced by LA Jensen's record review for R1. This poses a potential 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: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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