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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601069
Report Date: 03/23/2022
Date Signed: 03/23/2022 01:29:06 PM


Document Has Been Signed on 03/23/2022 01:29 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
CCLD Regional Office, 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: 14DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Desiree Alvarado; AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with staff Marivic Nacorda and explained the reason for the visit. Administrator Desiree Alvarado arrived shortly thereafter. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Administrator toured the facility and inspected the first floor which consists of 2 client bedrooms, 1 & 1/2 bathrooms, living room, dining room, kitchen, laundry room, staff room and an office. The second floor consists of 5 client bedrooms and 1& 1/2 bathrooms. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the back patio. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 (upstairs) and bathroom #2 (downstairs) and measured between 114.3F - 117.1F which is within the required 105F - 120F degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector located right outside the kitchen which is operable. There are multiple fire extinguishers located throughout the facility which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to clients. Cleaning supplies and disinfectants are locked and are inaccessible to clients. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Staff were observed wearing masks and screening visitors at entry.
  • LPA observed a sufficient 2 days perishable food supply, but not a sufficient 7 days non-perishable foods supply for the number of clients in care.
  • 5 client medications were reviewed at random. Medications are centrally stored in a kitchen cabinet. Medications are documented properly and given as prescribed.
  • Staff and Client files were not reviewed during today's visit.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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 03/23/2022 01:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
(d) The licensee shall meet the following food supply and storage requirements:

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on physical plant tour, LPA did not observe suficient supply of one week nonperishable foods for the current number of clients in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2022
Plan of Correction
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Licensee/Administrator to ensure supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises at all times. Licensee/Administrator to submit pictures and/or grocery store receipts demonstrating sufficient food supply is present at the facility by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
LIC809 (FAS) - (06/04)
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