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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 09/25/2026
Date Signed: 09/29/2026 10:29:11 AM

Document Has Been Signed on 09/29/2026 10:29 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BONNIE'S CARE HOMEFACILITY NUMBER:
502701087
ADMINISTRATOR/
DIRECTOR:		MARIA ARAIZAFACILITY TYPE:
740
ADDRESS:2608 VENEMAN AVENUETELEPHONE:
(209) 248-7663
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 5DATE:
09/25/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Tinesha Villagomez, Maxine Smith, and Maria AraizaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 09/25/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Maria Araiza who was briefly interviewed at this time.
Current census was 5 residents.
It was learned that there were (2) residents under the care of hospice at this time. It was learned that this facility does have an approved hospice waiver to be able to accept and retain up to 6 hospice residents at any given time.
It was learned that there were (2) residents deemed to have the diagnosis of dementia at this time. It was learned that this facility does have a dementia program on file at this time.
It was learned that there weren't any residents receiving services through home health at this time.
It was learned that there weren't any residents deemed to be bedridden at this time. This facility does not have an approved bedridden fire clearance at this time.
There were (2) other facility staff members, S1 and S2, present during this annual visit.
Tour of the facility was conducted.
A tour of the living area, dining area, and all other areas intended for resident use was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Cabinets and drawers were reviewed at this time. Drawers storing knives and sharps were reviewed to make sure that they were locked and made inaccessible to the residents at all times. Cabinets storing detergent and all cleaning supplies were reviewed to make sure that they were locked and made inaccessible to the residents at all times.
Facility restrooms were toured.
Grab bars and non skid mats were observed to be present and in good working order at this time.
Liza King
Charlie Yang
DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2026
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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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)
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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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087
VISIT DATE: 09/25/2026
NARRATIVE
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Hot water temperatures were taken to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees at all times.
A review of the facility medications for the residents was conducted. It was learned that all of the resident medications were centrally stored.
First aid kit, located in the facility medication locker located in the office area, was reviewed. It was observed that it did contain all of the required components and was in compliance at this time.
A review of the facility food supply was conducted. A tour of the facility pantry was conducted to make sure that there was a sufficient supply of 2-day perishables and 7-day non perishable food quantities on hand at all times.
It was learned that there was an additional refrigerator being used in the garage area.
Tour of the garage area was conducted. It was observed that this space was being used to store household items and personal items for the residents in care at this time.
Laundry area was toured. It was observed that the door leading into the laundry area did have the ability to be locked at this time. It was observed that the cabinets within the laundry area were equipped with a locking mechanism to be able to store detergents and bleach so that they were inaccessible to the residents at all times.
A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to be present and able to meet the needs of the residents at this time.
Linen closet, located in the facility hallway, was reviewed.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, (2) side gates, and all other exits was conducted.
A review of (5) facility resident files was conducted and noted on the following LIC 858.
A review of (2) facility staff files was conducted and noted on the following LIC 859.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2026 10:29 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/25/2026 at 01:16 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the hot water being dispensed from the resident restroom was measured at 121 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2026
Plan of Correction
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The facility designated Administrator stated that all faucets will be reviewed to make sure that they are dispensing hot water within the allowed range of 105-120 degrees at all times. A statement of correction, along with proof of measured hot water temperatures for the next 72 hours, will be completed and submitted into CCL by the due date for review by this LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2026 10:29 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/25/2026 at 01:16 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that [2] out of [2] facility personnel files did not contain proof of proper TB clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2026
Plan of Correction
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The facility designated Administrator stated that all facility personnel files will be reviewed to make sure that they have proper TB clearance at all times. A statement of correction, along with proof of all updated staff TB clearances, will be completed and submitted into CCL by the due date for review by this LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/29/2026 10:29 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/25/2026 at 01:16 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there was not a sufficient supply of 7-day non perishable food items available on site which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2026
Plan of Correction
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The facility designated Administrator stated that the food supply will be reviewed to make sure that there is an adequate supply of 7-day non perishable food quantities present at all times. A statement of correction, along with proof of purchased non perishable food items in the form of receipts, will be completed and submitted into CCL by the due date for review by this LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2026 10:29 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/25/2026 at 01:16 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that facility windows were missing window screens in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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The facility designated Administrator stated that all windows will be reviewed to make sure that they have a window screen in good condition without any rips, holes, or tears in them. A statement of correction, along with proof of all window screens being updated and in place in the form of receipts and photos, to be completed and submitted into CCL by the due date for review by this LPA.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the facility perimeter fence and side gates were in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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2
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The facility designated Administrator stated that the facility perimeter fence and side gates will be reviewed to make sure that they are in good repair and functional at all times. A statement of correction, along with proof of the perimeter fence and side gates being repaired/replaced in the form of receipts and photos, to be completed and submitted into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2026


LIC809 (FAS) - (06/04)
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