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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002714
Report Date: 08/21/2024
Date Signed: 08/21/2024 10:42:24 AM


Document Has Been Signed on 08/21/2024 10:42 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:BONHURST ASSISTED LIVING. CORP (HOUSE I)FACILITY NUMBER:
455002714
ADMINISTRATOR:SKEVIG, ANGELINA MANDRIAFACILITY TYPE:
740
ADDRESS:1306 BONHURST DRIVETELEPHONE:
(530) 244-8458
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 5DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator, Angelina Mandria SkevigTIME COMPLETED:
10:45 AM
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On August 21, 2024 at approximately 08:15 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Bonhurst Assisted Living Corp (House I) for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Caregiver, Rosario Mandria and was granted access into the facility. Administrator arrived 15 minutes later.

LPA and the Administrator toured the facility. LPA observed the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 2024 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the inspection. Water temperature in residents bathrooms measured at 109 degrees in 2 of 2 residents bathrooms and is within acceptable range of 105 to 120 degrees F. LPA observed sufficient perishable and non-perishable foods located in the kitchen and the garage refrigerator. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Medication orders for residents in care were reviewed and found to be appropriate during the inspection. First Aid Kit was inspected and found to be appropriate during the inspection. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 or other infectious diseases are present in the facility. Emergency Disaster Plan is currently being updated (See LIC 9102-Technical Advisory).

(Report continued on LIC 809C)
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BONHURST ASSISTED LIVING. CORP (HOUSE I)
FACILITY NUMBER: 455002714
VISIT DATE: 08/21/2024
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LPA reviewed staff files and found those files to be appropriate. LPA reviewed resident records and found those to be appropriate during the inspection.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Facility Responsibility
LIC 309- Administrative Organization
Updated Emergency Disaster Plan
Most up-to-date Liability insurance
Control of Property
Register of residents

LPA advised Facility Administrator to conduct a staff refresher course on Title 22 regulation-87211-Reporting Requirements (See LIC 9102-Technical Advisory). LPA also provided Technical Assistance on this matter and the importance of reporting incidents to Community Care Licensing. LPA educated the Administrator on contacting the Officer of the Day line and/or the LPA assigned to the facility if there are any questions.

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this signed report was printed and given to the Administrator.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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