502701087-8-21-2025-27-AS-ELIM-DKRUNA-20250821154338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 08/21/2025
Date Signed: 08/21/2025 03:44:00 PM

Document Has Been Signed on 08/21/2025 03:44 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	BONNIE'S CARE HOME		FACILITY NUMBER:	502701087
ADMINISTRATOR/ DIRECTOR:	LACY VINCENT		FACILITY TYPE:	740
ADDRESS:	2608 VENEMAN AVENUE		TELEPHONE:	(209) 248-7663
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 6		CENSUS: 4	DATE:	08/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:22 AM
MET WITH:	Maria Araiza, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 10:20 AM on 8/21/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by a caregiver. The LPA identified herself, explained the purpose of the visit, and requested to meet with the Administrator. A caregiver called the Administrator to inform her that the LPA was on site to conduct an annual inspection. The Administrator arrived at the facility at 10:30 AM and an inteview followed. The Administrator accompanied the LPA on a tour of the facility. This facility is licensed to serve six non-ambulatory residents and has a hospice waiver for six. The facility is a five-bedroom, 2-bathroom house located in a residential area. The census was four residents at the time of this site inspection, all of whom were at the facility at the time of the site inspection. There were two staff on duty when the LPA arrived at the facility. The LPA toured the inside of the house, including the bedrooms, bathrooms, kitchen, dining room, living room, laundry room and garage. The entire house was clean, odor-free, and pest-free. The windows and window screens were in good repair. The required documents were posted in the entry way and front room. The LPA toured the four resident bedrooms and one resident bathroom. There are two double-occupancy bedrooms and two single-occupancy bedrooms. Each bedroom contained the required furniture, including bed, bedside table, lamp, dresser, and chair. The LPA toured the bathroom. The bathroom contained grab bars, non-slip surfaces, and assistive devices. The LPA measured the water temperature at a bathroom sink. The temperature of the water was 120 degrees Fahrenheit, within the required range. The Administrator stated that staff tested the water temperature daily. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONNIE'S CARE HOME	FACILITY NUMBER: 502701087
	VISIT DATE: 08/21/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The LPA toured the kitchen. The kitchen was clean, the appliances were operable, and the trashcan had a lid on it. There was a seven-day non-perishable and two-day perishable supply of food located in the kitchen refrigerator-freezer and cabinets, as well as a refrigerator-freezer and storage container in the garage. There were flashlights in a kitchen drawer. The LPA observed that the drawer in the kitchen containing sharp objects was unlocked.

The LPA toured the dining room, living room, and hallway. The LPA observed a table and chairs in the dining room and a large couch in the living room that provided adequate seating for residents. There is a large TV in the living room. The LPA observed a fire extinguisher in the living room. The fire extinguisher was purchased on 9/4/2024. The fire extinguisher had never been used and was in the green. The LPA observed that the thermostat in the hallway displayed 79 degrees Fahrenheit. There were two smoke detectors and two carbon monoxide detectors in the hallway. The Administrator tested the smoke and carbon monoxide detectors and all were in working order. There were cabinets in the hallway that contained linens, resident care supplies, personal protective equipment, and a first aid kit. The first aid kit contained all the required items.

The LPA toured the laundry room and garage. The laundry room contained a washing machine and the staff bathroom. The LPA observed chemical cleaners in a cabinet above the toilet and a cabinet beneath the sink that were not locked. The garage contained the dryer and storage cabinets with incontinence care.

The LPA toured the front, back, and side yards. The LPA observed a shaded table and chairs in the backyard. The backyard lawn was manicured, and the backyard was enclosed with a wooden fence that was sturdy and intact.

The LPA inspected the central medication storage area. Resident medication and medication records were stored in a locked cabinet in the front office. Each resident's medication was stored in a separate container and all medication was in its original packaging with intact labels.

(Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONNIE'S CARE HOME	FACILITY NUMBER: 502701087
	VISIT DATE: 08/21/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The LPA inspected the paper-based medication administration record (MAR) and three medications for one resident (R1). The LPA observed that one medication bubble pack had one dose missing from it, but the medication was not listed in the MAR. There was no record of when the medication was administered. The LPA observed that another medication bubble pack had many doses missing from it. This medication was listed in the MAR but there were no staff signatures indicating when it had been administered.

The LPA reviewed records for two residents and two staff and found the records to be complete. Both staff records contained criminal background clearances, current first aid/CPR certifications, and TB tests. Both resident records contained health screenings, TB tests, admission agreements, and care plans.

The LPA requested that updated copies of the following documents be submitted to Licensing by 8/29/2025 at ellen.lindstrom@dss.ca.gov.

(1) LIC 308 Designation of Facility Responsibility
(2) Copy of a current Administrator Certificate
(3) LIC 610D Emergency Disaster Plan
(4) Proof of Liability Insurance
(5) LIC 500 Personnel Report
(6) LIC 309 Administrative Organization

As a result of this inspection, no deficiencies were cited. The facility was in compliance with the California Code of Regulations (CCR), Title 22, Division 6.

An exit interview was conducted with the Administrator, to whom a copy of this LIC809 report, the LIC 809D, and the appeals rights was provided. Their signature below confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4