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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005219
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:26:17 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2022 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 25-AS-20220914175632
FACILITY NAME:BONITA HOME CAREFACILITY NUMBER:
317005219
ADMINISTRATOR:POLYAKOVA, ANNAFACILITY TYPE:
740
ADDRESS:7189 LIVERPOOL LANETELEPHONE:
(916) 772-6667
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
05/04/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anna Polyakova, AdministratorTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings regarding allegations listed above. LPA met with Administrators Anna and Alena Polyakova during today's inspection.
The Department investigated allegation of questionable death. During the course of the investigation, the Department obtained hospital documentation, hospice documentation, and interviewed facility staff and relevant parties. Medical records indicate R1 was admitted to the hospital on 4/7/2020 with a chief complaint of a pressure injury. It was determined by hospital staff that R1 had a stage 3 pressure injury on the right sacral area and stage 1 and stage 2 pressure injuries on bilateral heels. R1 was placed on hospice and passed away in May 2020.
Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 25-AS-20220914175632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: BONITA HOME CARE
FACILITY NUMBER: 317005219
VISIT DATE: 05/04/2023
NARRATIVE
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The Department obtained a copy of R1’s death certificate and observed immediate cause of death was Alzheimer’s dementia. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

An exit interview was conducted. A copy of the report was provided to facility administrator.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2022 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 25-AS-20220914175632

FACILITY NAME:BONITA HOME CAREFACILITY NUMBER:
317005219
ADMINISTRATOR:POLYAKOVA, ANNAFACILITY TYPE:
740
ADDRESS:7189 LIVERPOOL LANETELEPHONE:
(916) 772-6667
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
05/04/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anna Polyakova, AdministratorTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Resident sustained pressure injury while in care.
Facility retained a resident that required a higher level of care.
Staff did not inform resident's authorized person of a change in health condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings regarding allegations listed above. LPA met with Administrators Anna and Alena Polyakova during today's inspection.
The Department investigated the allegation of resident sustained pressure injury while in care. During the course of the investigation the Department obtained hospital documentation, hospice documentation, and interviewed facility staff and relevant parties. On 04/06/2020, the facility sought emergency medical services for R1. Medical records reflect that R1 was admitted to the hospital on 04/07/2020 with a chef complaint of pressure injury to their buttock and sacrum. Emergency Department notes indicated R1 arrived directly from Bonita Facility for treatment of a pressure injury on the right sacral area and bilateral heels that were identified by facility staff about a week prior.
Continuation on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 25-AS-20220914175632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: BONITA HOME CARE
FACILITY NUMBER: 317005219
VISIT DATE: 05/04/2023
NARRATIVE
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Upon physical exam by hospital staff at admittance, it was determined that R1 had a stage 3 pressure injury on the right sacral area and stage 1 and stage 2 pressure injuries on bilateral heels. The Department interviewed licensee, in which licensee stated R1’s pressure injury to their coccyx worsened over a “couple days” after it was discovered by staff. Licensee stated they attempted to get R1 an appointment to see their primary care physician but was unsuccessful and therefore sent R1 to the Emergency Department for treatment. Licensee stated that the pressure injuries to R1’s heel and coccyx happened “within hours” of each other. The Department interviewed R1’s primary care physician in which they stated it is “doubtful” that R1’s pressure injuries worsened to the extent they were upon admittance to the hospital, over a period of one or two days. The pressure injury on R1’s coccyx appeared deep, as in something that occurred over a “longer period of time". Due to the information gathered, the Department finds allegation to be SUBSTANTIATED.
The Department investigated allegation of Facility retained a resident that required a higher level of care. During the course of the investigation, the Department obtained hospital documentation, hospice documentation, and interviewed facility staff and relevant parties. Medical records reflect that R1 was admitted to the hospital on 04/07/2020 with a chief complaint of a pressure injury to their buttock and sacrum. Emergency Department notes that R1 arrived directly from Bonita Facility for treatment of a pressure injury on the right sacral area and bilateral heels that were identified by facility staff about a week prior.

Continuation on 9099-C.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 25-AS-20220914175632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: BONITA HOME CARE
FACILITY NUMBER: 317005219
VISIT DATE: 05/04/2023
NARRATIVE
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Upon physical exam by hospital staff at admittance, it was determined that R1 had a stage 3 pressure injury on the right sacral area and stage 1 and stage 2 pressure injuries on bilateral heels. Due to the information gathered, R1 had a stage 3 pressure injury which pursuant to CCR, Title 22 §87615 is considered a Prohibited Health Condition. LPA finds allegation to SUBSTANTIATED.

The Department investigated allegation of staff did not inform resident’s authorized person of a change in health condition. During the investigation the Department obtained hospital documentation and interviewed facility staff and relevant parties. LPA interviewed licensee and administrator in which they stated they informed R1’s representative of all changes and incidents that occurred with R1 at the facility. Licensee sent LPA emails that were sent between facility staff and R1’s representative. LPA interviewed relevant parties in which they stated facility did not inform R1’s representative of a fall that occurred (4) four days prior to R1’s hospitalization on 04/07/2020. The relevant party indicated facility did notify R1’s representative that R1 had (1) one wound and that R1 was going to the hospital but facility did not notify them of the severity of R1’s condition. LPA reviewed hospital documentation and learned on 04/06/2020 a caregiver called the medical advice line and indicated R1 fell from their wheelchair (4) four days prior to hospitalization. Due to the information gathered LPA finds that R1 had a fall and facility staff did not inform R1’s representative. LPA finds allegation to be SUBSTANTIATED.

Continuation on 9099-C.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 25-AS-20220914175632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: BONITA HOME CARE
FACILITY NUMBER: 317005219
VISIT DATE: 05/04/2023
NARRATIVE
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As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D.

Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 25-AS-20220914175632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BONITA HOME CARE
FACILITY NUMBER: 317005219
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited
CCR
87466
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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Administrator agrees to attend a training from an outside agency with all care staff on skin care and repositioning residents. The training date to be submitted into LPA on 5/05/23.
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This requirement is not met as evidenced by: Based on record review R1 sustained a pressure injury while in care which posed an immediate health and safety risk to residents in care.
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Once training is complete, administrator to send into LPA subject matter of the training and sign in sheet of who attended the training.
Type A
05/05/2023
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:
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Administrator agrees to review 87615 prohibited health conditions. Administrator to submit a statement of understanding of what prohibited conditions are not permitted at the facility.
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This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee obtained resident (R1) with a prohibited health condition, without an approved exception, which posed an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 25-AS-20220914175632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BONITA HOME CARE
FACILITY NUMBER: 317005219
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Administrator agrees to provide a training to all care staff concerning reporting requirements. Administrator to send into LPA
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This requirement is not met as evidenced by: Based on record review and interviews, the licensee failed to report incident to responsible party which poses a potential health and safety risk to residents in care.
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 subject matter of training and sign in sheet of who attended the training by 5/12/23.
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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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8