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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601069
Report Date: 04/22/2022
Date Signed: 04/22/2022 11:03:07 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20210921074709
FACILITY NAME:BONNIE'S GUEST HOUSE INC.FACILITY NUMBER:
198601069
ADMINISTRATOR:ALVARADO, DESIREEFACILITY TYPE:
735
ADDRESS:135 NORTH BONNIE AVENUETELEPHONE:
(626) 440-0494
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:14CENSUS: 14DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Marivic Nacorda - Direct Care StaffTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Illegal eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) Mary Flores conducted a complaint investigation visit regarding the above allegation(s). LPA Flores met with Marivic Nacorda direct care staff and explained the reason of the visit.

The investigation consisted of the following; On 9/24/21 LPA(s) Flores and Baptiste requested copies of staff and client roster, eviction letters provided to clients for September, physician's report, admissions agreeement, house rules, and face sheets for client #1(C1),#2(C2),#3(C3),#4(C4),#5(C5),#6(C6). LPAs interviewed administrator, staff #1, #2, and clients #1,#2,#3,#4,#5. On 2/19/21 LPA Flores interviewed Client #6(C6) over the phone. LPA Flores requested copies of house rules and additional resident's personal rights/disciplinary action procedure/eviction procedure letters, and psychological evaluation for C1,C2,C3,C4,C5,C6. On 4/22/22 LPA Flores delivered findings at the facility.

The investigation revealed the following: Regarding allegation: Illegal eviction, it is alleged client was provided an eviction notice on 8/24/2021 for giving another client drugs, which is false.
(CONTINUED LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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 3
Control Number 28-AS-20210921074709
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BONNIE'S GUEST HOUSE INC.
FACILITY NUMBER: 198601069
VISIT DATE: 04/22/2022
NARRATIVE
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Interviews with 4 out of 6 clients stated C1 either smoke in room or used/offered drugs at the facility. 2 out of 6 clients stated to have smell smoke coming from C1's room but were not aware of who was smoking. Interviews with staff revealed 3 out of 3 staff stated that C1 smokes inside the room and has been warned multiple times. Documents reviewed revealed admissions agreement signed by clients states eviction procedures; "The licensee will present the resident with a 30 day written notice, for one or more of the following reasons: ...c) Failure to comply with the ..(House Rules)...d) Use of recreational drugs and/or alcohol in or outside the premises. g.) Smoking/Vaping in the room... 30 Day Eviction Letter states facility has been made awared that C1 has been violating facility's house rules by using and dealing illegal drugs in room and premises and has been warned multiple times that smoking indoors is not permitted. Facility's Resident's Personal Righrs Disciplinary Action Procedure states that the procedure is to provide a verbal warning for the 1st violation, a written warning for the 2nd violation, and an eviction letter for the 3rd violation. LPA reviewed facility's department file for incident reports submitted regarding related incidents there was one incident report submitted on 8/24/21 for the period between June 2021 to December 2021. The facility provided a written warning on 8/24/21 to C6 for violating or using illegal drugs at the facility. On 8/18/21 LPA Flores received a call from Administrator Desiree Alvarado in which LPA recommended to follow her written procedures in place regarding evictions and to ensure to submit an incident report for any incidents. Although the behavior may be true the facility did not follow disciplinary action procedures equally with C1 and C6.

Based on LPA's interviews and documents review conducted the preponderance of evidence standard has been met, therefore the allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Marivic Nacorda Direct Care Staff and a copy of this report LIC 9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 28-AS-20210921074709
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BONNIE'S GUEST HOUSE INC.
FACILITY NUMBER: 198601069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
85068.5(a)(4)
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85068.5 Eviction Procedures: (a) The licensee shall be permitted to evict a client... with a 30 day written notice to quit for... the follwoing reasons: (4) A needs an services plan modification has been performed...which determined that the client's needs cannot be met...
This requirement is not met as evidence by:
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Administrator shall read regulation 85068.5 and shall submit a statemetn acknowledging and adhering to the regulations to the department by POC due date 4/29/22.
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Based on interviews and documents reviewed administrator did not ensure to follow written disciplinary action procedures, and submit incident reports of the notice behaviors to the department which poses a potential risk to the health, safety, or personal rights of persons 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.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
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