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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005219
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:28:58 PM

Document Has Been Signed on 05/04/2023 12:28 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anna Polyakova, AdministratorTIME COMPLETED:
12:40 PM
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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.
On May 4, 2023, the Department concluded a complaint investigation. During the course of the complaint investigation, it was learned that facility staff did not seek timely medical attention for R1 regarding pressure injuries. Interviews indicated staff were aware R1 had several pressure injuries that were worsening and resident had an overall decline. Resident had been less mobile over the last 3-4 days prior to being sent to hospital, staying in bed most of the time and was not eating or drinking for multiple days. Once admitted to the hospital on April 7, 2020, R1 was diagnosed with a stage 3 pressure injury to their right sacral area resulting in hospitalization. Facility staff stated they reached out to R1’s primary care physician on April 6, 2020. Staff claimed they noticed a skin breakdown worsening with an apparent odor, and waited for resident’s PCP to call back instead of bringing R1 to the hospital right away. Based on facility staff’s acknowledged observations of R1’s worsening condition, facility staff failed to provide care and supervision and delayed timely medical treatment that resulted in hospitalization for Unstageable, Stage 3 and Deep Tissue Injury. Deficiencies are being cited for violating the following California Code of Regulations (CCR) Title 22:
87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).

Continuation on 809-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
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: 05/04/2023
NARRATIVE
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 Today, May 4, 2023, the Department will be issuing an immediate civil penalty in the amount of $500 shall for a violation of Section 87465 (g), and the license was informed that an additional civil penalty was still being determined and may be assessed based on Health and Safety Code Section 1569.49.

A copy of LIC 421 was given to the facility representative. 

Exit interview conducted.  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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/04/2023 12:28 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 05/04/2023 at 12:06 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
, 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
87465(g)

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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Administrator agrees to attend a training from an outside agency with all care staff on emergencies and emergency intervention. 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 interviews and record review, the licensee did not obtain medical attention in a timely manner which poses 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.

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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: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


LIC809 (FAS) - (06/04)
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