502701087-8-7-2023-27-AS-KVIA-CUH7C5-20230807213211

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 08/07/2023
Date Signed: 08/07/2023 09:33:14 PM

Document Has Been Signed on 08/07/2023 09:33 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	BONNIE'S CARE HOME		FACILITY NUMBER:	502701087
ADMINISTRATOR:	YEPEZ, BONAIRE		FACILITY TYPE:	740
ADDRESS:	2608 VENEMAN AVENUE		TELEPHONE:	(209) 272-4444
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	6	CENSUS: 5	DATE:	08/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Bonaire Yepez, Licensee		TIME COMPLETED:	06:00 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

Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 08/07/23. LPA identified herself to the Caregiver on duty, explained the purpose of the visit, and asked to speak with Bonaire Yepez, the Licensee/Administrator. A brief interview followed. Census at the time was 5 residents in care.

LPA noted the Licensee/ Administrator, Bonaire Yepez’s, certificate (# 6059821740, expiration date 06/09/2023) was posted along with the facility’s license. The Licensee has another Certified Administrator who is associated to the facility, who has agreed to assist with coverage while the Licensee renews her certification.

The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were all dated appropriately.

LPA inspected the 5 bedrooms, all had the required furniture, furnishings and lighting to be in compliance at this time. The LPA observed grab bars and non-skid surfaces in the 2 resident bathrooms at this facility.

The hot water temperature was measured at 107.6 degrees Fahrenheit and was in compliance. The fire extinguish was last serviced on 10/25/2022 by Jorgensen Co. and was also in compliance.

LPA inspected the medications and logs which were kept in a locked cabinet and inaccessible to residents. LPA reviewed dosing, storage, and destruction practices with staff. First Aid kit was also reviewed to ensure compliance.

The exterior of the building was inspected by the LPA. LPA also observed 2 screens on the right side of the

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BONNIE'S CARE HOME	FACILITY NUMBER: 502701087
	VISIT DATE: 08/07/2023

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

house, 2 in the rear, along with the sliders, 1 on the right side and 1 in the front were damaged and did not fit properly. The fenced-in yard was clear of debris. There was a locked storage shed. LPA found it to contain a lawn mower and other maintenance equipment. There was also a covered patio area for residents to enjoy.

LPA completed a review of resident files to ensure compliance. LPA provided some technical assistance with the Appraisal/Needs and Services Plan. Staff files were reviewed as well, and annual training will be due in September and October.

During the review of resident files LPA observed that 2 of the 5 residents were bedridden. The LIC 602's had not been updated. The Licensee immediately contacted the physician's office and new LIC 602s were provided to this LPA before the completion of the inspection.

LPA requested the following Documents:
Updated LIC 308
LIC 500
LIC 9020
Updated LIC 200 for a new Fire Clearance for Bedridden
Updated Facility Sketch
Administrator's Certification Renewal
Copy of Liability Insurance

According to the California Code of Regulations, Title 22, the following deficiencies were observed and cited on the LIC 809 D page.

A copy of this report was provided to the Licensee along with the Appeal Rights.

Exit interview.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 08/07/2023 09:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BONNIE'S CARE HOME	FACILITY NUMBER: 502701087
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above when 2 out of 5 residents transitioned to a bedridden condition without having the proper fire clearance in place. This which poses/posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2023
	Plan of Correction
1 2 3 4	The Licensee will submit an updated LIC 200 with an updated facility sketch to kimberly.viarella@dss.ca.gov by the close of business on 08/08/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 08/07/2023 09:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BONNIE'S CARE HOME	FACILITY NUMBER: 502701087
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.627(i)

Other Provisions

(i) Changes in condition, including, but not limited to, when and under what circumstances are changes made to a participant's care plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 of 5 residents when they transitioned to bedridden, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2023
	Plan of Correction
1 2 3 4	The Licensee has already corrected this deficiency by obtaining updated physician's reports.

Type B

Section Cited

HSC

1569.652

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Termination of admission agreement upon death or a resident... refund of fees paid... notice of contract termination Based on interview and record review, the licensee did not comply with the section cited above when they included a section in their admissions agreement refusing to refund money to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2023
	Plan of Correction
1 2 3 4	Licensee shall update their admissions application to include an appropriate refund policy and will submit it to kimberly.viarella@dss.ca.gov by 08/30/2023.

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: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 08/07/2023 09:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BONNIE'S CARE HOME	FACILITY NUMBER: 502701087
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

This requirement is not met as evidenced by: Maintenance and Operation 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above when 8 screens out of the total number of windows and sliders that the facility possessed were damaged. LPA witnessed insects inside the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2023
	Plan of Correction
1 2 3 4	The Licensee shall have all screens repaired so they prevent insects from entering the facility. Pictures of the repaired windows / sliders will be submitted to kimberly.viarella@dss.ca.gov by 08/30/2023. The Licensee will also submit a copy of the pest control bill with the date stamp showing the day the facility was treated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6