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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005219
Report Date: 07/11/2024
Date Signed: 07/11/2024 11:51:19 AM

Document Has Been Signed on 07/11/2024 11:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
317005219
ADMINISTRATOR/
DIRECTOR:		POLYAKOVA, ANNAFACILITY TYPE:
740
ADDRESS:7189 LIVERPOOL LANETELEPHONE:
(916) 772-6667
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
07/11/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Alena and Anna Polyakova, Licensee and AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On July 11, 2024, Licensing Program Analysts (LPA) Bethany Mirlohi conducted a case management visit to follow up on a deficiency cited for the facility not ensuring timely medical attention was provided to a resident in care. LPA Mirlohi met with Licensee Alena Alla Polyakova and explained the purpose of the visit.

On May 4, 2023, the Department concluded a complaint investigation and substantiated the following allegations: a resident sustained pressure injuries while in care; facility retained a resident that required a higher level of care; and staff did not inform resident’s authorized person of a change in heath condition.

The licensee was cited for California Code of Regulations (CCR) Title 22, Section 87466 Observation of the Resident; 87615 Prohibited Health Conditions(a)(1); and 87211 Reporting Requirements. In addition, the licensee was cited for CCR 87465(g) Incidental Medical and Dental Care: (g) for failure to seek timely medical attention. An immediate civil penalty in the amount of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and may be assessed based on Health and Safety Code Section 1569.49.

Continuation on 809-C.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/11/2024
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The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code Section 15610.67, “Serious bodily injury” means an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation. This is evidenced by the facility licensee and staff acknowledging they were aware that a resident’s (R1) pressure injuries were worsening and failed to seek timely medical attention for R1’s injuries, which resulted in hospitalization for an unstageable, stage 3, and deep tissue pressure injuries.

Today, July 11, 2024, the Department will be issuing a civil penalty per Health and Safety Code Section 1569.49(f). The Department will be issuing a $10,000 civil penalty for the violation the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on May 4, 2023, a civil penalty in the amount of $9,500 will be issued.

A copy of the LIC 421D was given to the facility representative.  
  
Exit interview conducted.  Appeal Rights provided.  A copy of the report issued.  Signature on these reports acknowledges receipt of these rights, found on page 2 of LIC 421D.  
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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