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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601069
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:29:10 PM

Document Has Been Signed on 03/05/2024 12:29 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
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: 14DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Silvina Gomez - StaffTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Silvina Gomez and explained the reason for the reason.

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 conducted a tour with Silvina Gomez and observed the following:
Facility is in good repair indoor and outdoor. Living room/dining room sufficient seating area, clean, fireplace is covered. Kitchen is clean, knives are stored in a drawer and cleaning supplies under sink, medication cabinet was observed. Kitchen is inaccessible to the clients. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Refrigerators (2) and freezers (3) were observed in kitchen and garage without thermometers unable to check temperature. Client's rooms (8) were observed each with sufficient lighting, furniture, and bedding supplies. Bathrooms (3) were observed clean, in good repair, and water temperature was tested between 107.4-110.8 degrees F., which is within the required 105-120 degrees F. Laundry area was observed next to room #2. Detached garage is used to stored supplies. The backyard has a covered sitting area and there is a front porch with furniture. Carbon monoxide/ smoke detectors were tested and are in working condition. Fire extinguishers were lasted checked on 7/9/2022. Stairs and passageways were clear of debris.
LPA reviewed medication and files for 5 clients. Client #4(C4) does not have a physician's report signed by the physician. LPA reviewed 5 staff files, emergency disaster plan, infection control plan. Last fire drill was conducted on 6/7/23. Administrator certificate for Desiree Alvarado was reviewed for renewal #6004637735 exp. 12/16/23. HIV/TB training for administrator was not available for review. Staff training was reviewed no record of medication training available.
Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Silivina Gomez and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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 03/05/2024 12:29 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/05/2024 at 11:39 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation and record review, the licensee did not comply with the section cited above in no evidence of HIV/TB training for administrator was available for review during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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Administrator will provide a copy of HIV/TB training certificate to the department by POC due date 3/12/24.
Type B
Section Cited
CCR
80065(f)(4)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in no record of medication training provided to staff was available for review at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Administrator will ensure staff who provide medication to the clients are trained by a pharmacist or training professional on medication assistance and provide a copy of training (with duration, log, and topic) or certificate by POC due date 3/19/24.
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: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/05/2024 12:29 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/05/2024 at 11:39 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(2)
Food Service
(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in three freezers observed, 1 in kitchen and 2 in the garage did not have a thermometer to read temperature of freezers available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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Administrator will provide a thermometer in each freezer and will submit a picture to the department by POC due date 3/12/24.
Type B
Section Cited
CCR
85076(d)(3)
Food Service
(3) Refrigerators shall be large enough to accommodate required perishables and shall maintain a maximum temperature of 45 degrees F (7.2 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two refrigerators, 1 in kitchen and 1 in garage did not have a thermometer available to read temperature of refrigerators which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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Administrator will provide a thermometer in each refrigerator and will submit a picture to the department by POC due date 3/12/24.
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: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/05/2024 12:29 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/05/2024 at 11:39 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(8)
Needs and Services Plan
80070 Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069.


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 physician's report for C4 was not filled out/signed by physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Administrator will obtain a signed copy of physician's report for C4 and will submit a copy to the department by POC due date 3/19/24.
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 last fire drill was conducted on 6/7/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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Administrator will conduct a fire drill with clients and staff and will provide a copy of log to the department by POC due dtae 3/12/24.
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: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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