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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601069
Report Date: 03/27/2023
Date Signed: 03/27/2023 12:47:34 PM

Document Has Been Signed on 03/27/2023 12:47 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
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: 13DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Silvina Gomez - Caregiver TIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit using the CARE tool at the facility. LPA Flores met with Silvina Gomez caregiver and explained the reason for the visit. Administrator Desiree Alvarado arrived 40 minutes later.

The facility is licensed to served 14 ambulatory mentally ill clients between the ages of 18 to 59 years old. The facility is a two story home in a residential area and consist of; first floor: a living room, a kitchen, 2 client rooms, laundry area, 1 bathroom, an office with access to the basement, and a staff room. Second floor: 7 client bedrooms, and 2 bathrooms. A backyard, a front yard, a detach garage and a shed.

LPA Flores conducted a tour of the facility with Silvina Gomez caregiver and observed the following:
First floor: Living room has sufficient sitting area, a covered fireplace. Kitchen was observed and a medication cabinet was observed, sharps were observed in a drawer to the left of the sink, kitchen is maintain lock when staff is not in the kitchen. Medication and knives are inaccessible to the clients. All bedrooms have sufficient lighting, bedding supplies, and furniture. Bathrooms are in working condition and water temperature was measured between 105 - 113.1 degrees F., which is within the required 105-120 degrees F. Fire extinguishers were observed last checked on 7/9/22. Smoke/carbon monoxide detectors were checked and in working condition. Backyard has a cover sitting area. LPA Flores reviewed medication and interview 3 clients, and interview 2 staff present at the time of the visit. LPA reviewed 5 client files and 4 staff files available. Client files were missing TB test for client #1(C1),#2(C2),#4(C4), and #5(C5). Staff files did not have current first aid or training provided for staff#1(S1),#2(S2),#3(S3),#4(S4). Administrator does not have a current HIV/TB training within the last 2 years. LIC 610D (10/03) was reviewed, licensee will update to LIC610D(12/21). Certificate was observed for Desiree Alvarado #6004637735 exp: 12/16/23 and a copy of liability insurance was requested.
Deficiencies will be noted on LIC 809D per Title 22 regulations.
Exit interview was conducted with Desiree Alvarado administrator and a copy of this report, LIC 809D, technical advisory,and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 03/27/2023 12:47 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/27/2023 at 11:32 AM
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
, 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(e)(4)
Plan of Operation
(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to: (4) Documentation of training the licensee and/or staff have completed specific to the needs of these clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 4 staff files review do not have training available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Administrator will provide staff training on daily living activities of the clients to staff and will submit a copy of the training and sign in sheet to the department by POC due date 4/10/23.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in administrator does not have a current HIV/TB training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Administrator will obtain HIV/TB training, will maintain a copy on file and submit a copy to the department by POC due date 4/10/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/27/2023 12:47 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/27/2023 at 11:32 AM
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
, 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff files reviewed have first aid training completed on 7/18/09 or no first aid available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Administrator will provide First aid training for staff and will submit a copy of training for S1, S2,S3, S4 to the department by POC due date 4/10/23.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 5 client files reviewed had a current physian report and TB test was not available as it could be in the previous physician report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Administrator will ensure a TB test is conducted for clients in care and will submit a copy of TB test results to the deparmtent for C1,C2,C4,C5 by POC due date 4/10/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/27/2023 12:47 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/27/2023 at 11:32 AM
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
, 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in LIC 610D was not update to the current (12/21) version which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Administrator will update LIC 610D to version (12/21) and will submit a copy to the department by POC due date 4/10/23.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in no record of fire drills was available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Administrator will provide a fire/emergency drill at the facility and will submit a copy of fire drill provided by POC due date 4/10/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
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