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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601069
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:48:25 PM

Document Has Been Signed on 03/20/2025 03:48 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/
DIRECTOR:		ALVARADO, DESIREEFACILITY TYPE:
735
ADDRESS:135 NORTH BONNIE AVENUETELEPHONE:
(626) 440-0494
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 14CENSUS: 13DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Silvina Gomez - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:00 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 TV/ dining 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. TV/dining room sufficient seating area, clean, fireplace is covered. A computer with access to the internet and a telephone were observed in TV room area. 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.
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 116.2 - 132.6 degrees F., which is not within the required 105-120 degrees F. Laundry area was observed next to room #2. Detached garage is used to stored supplies and additional food. 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 3/14/24. Stairs and passageways were clear of debris and obstructions. The facility has two stairways, one indoor and one in the exterior. LPA did not observed evacuation chairs either at the top or bottom of those stairways.

LPA reviewed medication and files for 5 clients and 5 staff files. LPA conducted interviews with 2 clients and 1 staff. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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 03/20/2025 03:48 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/20/2025 at 03:17 PM
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: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 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 water temperature was tested in bathroom #2(upstairs) at 132.6 degrees F., and in bathroom #3(downstairs) at 126.3 degrees F., which is not within the required 105-120 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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Administrator will adjust water heater and will certify in writing that will ensure water temperature is within the required 105-120 degrees F., by POC due date 3/21/25 and will maintain a temperature log for 7 days and will provide a copy of daily log to the department by 3/28/25.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2025 03:48 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/20/2025 at 03:17 PM
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: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation and record review, the licensee did not comply with the section cited above in last fire drill was conducted on 11/22/24 and the previos one was conducted on July 2024 per records they have not been conducted every quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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Administrator will conduct a fire drill and will ensure each fire drill is conducted quarterly and will submit a copy of log to the department by POC due date 3/27/25.
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

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 there are two stairways in the facility and LPA did not observe evacuation chairs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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Administrator will obtain evacuation chairs and will either take a picture of the chairs either at the top or bottom of each stairway or send a receipt of the purchase by POC due date 3/27/25.
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: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 03/20/2025
NARRATIVE
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Administrator certificate for Desiree Alvarado was observed #7001202735 exp. 12/16/25. HIV/TB training was last taken on 11/21/23. Staff training was reviewed.

Emergency disaster plan last updated on 1/22/25 and infection control plans were reviewed. Last fire drill was conducted on 11/22/24.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Silvina 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: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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