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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601069
Report Date: 03/19/2024
Date Signed: 03/19/2024 02:12:16 PM

Document Has Been Signed on 03/19/2024 02:12 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: DATE:
03/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Desiree Alvarado - AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction(POC) visit to follow up on deficiencies noted on 3/5/24.

On 3/5/24 LPA Flores conducted an annual visit. During the visit the following deficiencies were noted:
Section - CCR 85064(k) Administrator Qualifications and Duties: During the visit on 3/5/24 there was no evidence of HIV/TB training for administrator was available for review during the visit. On 3/12/24 Administrator submitted a copy of certificate for HIV/TB training taken on 11/21/23. Deficiency cleared as of 3/19/24.
Section - CCR 80065(f)(4) Personnel Requirements: During the visit on 3/5/24 there was no record of medication training provided to staff was available for review at the time of the visit. Administrator scheduled training for staff on medication for 3/22/24 with a pharmacist and will send log on 3/22/24 by end of day.
Section - CCR 85076(d)(2) Food Service: On 3/5/24 three freezers observed, 1 in kitchen and 2 in the garage did not have a thermometer to read temperature of freezers. On 3/19/24 LPA observed temperature in freezer at 0 degrees F. The other two freezers are not being used. Deficiency cleared as of 3/19/24.
Section - CCR 85076(d)(3) Food Service: On 3/5/24 two refrigerators, 1 in kitchen and 1 in garage did not have a thermometer available to read temperature of refrigerators. On 3/19/24 LPA observed temperature under 45 degrees F. in both refrigerators. Deficiency cleared as of 3/19/24.
Section CCR 80070(b)(8) Needs and Services Plan: On 3/5/24 physician's report for C4 was not filled out/signed by physician. Administrator requested an extension on 3/15/24 for this section as C4's physician takes over 30 days to provide physician's report. On 3/19/24 physician's report for C4 was observed. Deficiency cleared as of 3/19/24.
Section HSC 1565(c) Other Provisions: On 3/5/24 LPA observed last fire drill was conducted on 6/7/23. On 3/19/24 LPA observed Fire Drill long conducted on 3/15/24. Deficiency cleared as of 3/19/24.

Exit interview was conducted with Desiree Alvarado and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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