Bonnie's Care Home

Type of visit: Required - 1 Year

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. 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 Interviewthe state’s words, verbatim · CDSS document, Sep 25, 2026

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 09/25/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated representative Maria Araiza. A brief interview was conducted with the facility designated representative at this time. Current census was 5 residents. The purpose of this visit was to follow up on the deficiencies that were cited from a prior complaint visit conducted on 06/15/2026. This visit was to follow up on the Plan of Correction that was due. The following deficiencies were observed and cited on 06/15/2026: 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). Plan of Correction clearance letter was printed and a copy was provided to the facility designated representative at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Sep 25, 2026

Allegation investigated: Staff did not ensure resident received medical care in a timely manner

Unannounced complaint visit made out to this facility on 06/15/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Maria Araiza, who was interviewed at this time. Current census was 5 residents. The purpose of this visit was to deliver the findings from this investigation to this facility, and its representative, at this time. Based on interviews conducted during the course of this investigation, it was learned that facility staff who were scheduled on shift would initially always contact the facility designated Administrator prior to making any decisions to reach out for emergency services. It was learned that R1 sustained (2) falls at this facility in the month of February 2026 and rather than calling 911 for emergency services and further evaluation at the local emergency room, facility staff reached out to the facility designated Administrator first to seek for permission to make the call for emergency intervention. It was learned that the resident, R1, sustained an injury from the fall which required a surgical procedure Substantiated involving facility residents sustaining any injuries or requiring transportation to the hospital. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interview with follow up rehabilitation from a local skilled nursing facility at that time. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 15, 2026 · control 27-AS-20260221164814

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jun 16, 2026

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). This facility was found to be deficient as evidenced by learning that facility staff would contact the facility designated Administrator first before immediately calling 911 for threats to resident health and safety. This posed an immediate risk to the health, safety, and personal rights to residents in care.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: The facility designated Administrator stated that all facility staff will undergo training, for no less than (1) hour in duration, on the topics of resident rights and immediate notification to 911. A statement of correction, along with documented proof of updated training, will be conducted and completed with submission into CCL by the due date for review by this LPA. Proof of training will include the topics covered for training, name of trainer(s), duration of training, and name of all attendees.

Allegation investigated: Staff did not meet resident's incontinence needs. Staff denied resident visitors.

Unannounced complaint visit made out to this facility on 06/15/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Maria Araiza, who was interviewed at this time. Current census was 5 residents. The purpose of this visit was to deliver the findings from this investigation to this facility, and its representative, at this time. Based on a review of the forms and documents collected during the course of this investigation, it was learned that this facility did not provide any incontinence supplies to the residents in care unless it was opted for upon admission. It was learned that incontinence supplies were an additional item that would result in additional fees being charged on top of the established basic services fee. It was learned that this resident, R1, and their responsible parties did not opt to have incontinence supplies included in the basic service fee and opted to privately order and send them to this facility. Based on a review of the forms and documents collected during the course of this investigation, it was learned Unsubstantiated that the facility visiting hours were clearly posted. It was learned that the visiting hours were posted for the time frame of allowing visitors from 10:00 am to 7:00 pm every day. It was learned that these visiting hours were also present in the Admission Agreement which required the resident, and their responsible parties, to initial upon completion of the admission process. It was observed that the admission agreement for R1 was signed by all involved parties and Section 22 Facility Visiting Policy was initialed as well by the facility resident. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 15, 2026 · control 27-AS-20260227140647

Type of visit: Required - 1 Year

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) 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) 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.the state’s words, verbatim · CDSS document, Aug 21, 2025

Allegation investigated: Facility has new owner Facility is over charging resident

Licensing Program Analyst (LPA) Albert Johnson arrived at the facility unannounced to deliver findings for the above allegation. LPA was greeted by staff, staff contacted Administrator via phone. LPA explained the reason for the visit and was later joined by the Administrator. Allegation: Facility has new owner. The facility was planning on changing ownership and paper work was submitted, however the department requested a withdrawal of current application due to the need to have fire clearances completed and facility to have fire door arms to be replaced and locks to be cleared for usage. Unsubstantiated Allegation: Facility is over charging resident. R1 was admitted with identified functional assessment that have changed as a result of R1's lack of mobility. The facility reassessed R1 and determined that R1 needed additional support that change since the pre assessment and required the facility to provided additional support for R1 based on the ambulatory status change and incontinence care. Based on records reviewed the allegations are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 27-AS-20250108083015

Allegation investigated: Lack of adequate food service

On 12/19/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegstions. LPA Jensen met with care provider Sandra Williams and explained the purpose of today's visit. Maria Araiza arrived on the scene shortly after. LPA Jensen inspected the food supply and observed 2 days worth of perishable food and 7 days worth of non-perishable food. The non-perishable food consisted of a limited nnumber of canned goods and dry food plus a 30 day supply of emergency food for 1 person. Based on LPA Jensen's observation of the food supply on 2 seperate occassions the allegation of "lack of adquate food service" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. The posted menu for this day states that chicken fajita tacos will be served for dinner but the facility lacks the ingredients to make what's on the menu. Technical assistance was provided. An exit itervew was conducted and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 19, 2024 · control 27-AS-20241206152840

Type of visit: Case Management - Deficiencies

On 12/19/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced. LPA Jensen met with care provider Sandra Williams and explained the purpose of today's visit. Maria Araiza arrived on the scene shortly after. On 12/10/24 LPA Jensen reviewed a resident file for resident 1 (R1). There was no record to document the needs and services that the resident will be provided with. Technical assistance was provided on social factors and change in administrator. A deficiency is being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. A exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87467(a) · Plan of correction due date: Jan 16, 2025

Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any... to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This requirement was not met as evidenced by LA Jensen's record review for R1. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: The Licensee agrees to create a new needs and service plan template and to send revised needs and service plans for all residents to the Department by the POC due date.

Allegation investigated: Staff did not ensure residents personal possessions were safely secured

On 12/10/2 Licensig Program Analyst (LPA) Maja Jensen arriived at facility to open a complaint investigation in to the above liisted allegations. LPA Jensen met with Maria Araiza and explained the purpose of today's visit. LPA asked when the Administrator is present. Maria advised that she come in on weekends. LPA Jensen requested copies of documents from the file of resident file for resident 1 (R1). LPA Jensen was advised that the copier is not working this time. LPA Jensen reviewed the file and observed the client//resident personal property and valuables (LIC 621) to be blank. LPA Jensen asked Maria what the facility policy is regarding safeguarding personal property. Maria stated that items are labeled with the resident's name and logged. LPA Jensen asked if R1 came to the facility with any personal belongings. Maria replied that R1 came with the clothing that he was wearing and then his family also brought items. Substantiated Based on LPA Jensen's observation of a blank LIC 621 and the interview conducted with Maria Araiza the allegation of Staff did not ensure residents personal possessions were safely secured" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. In this instance the facility did not follow it's own policies for safeguarding resident valuables or theft and loss prevention. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2024 · control 27-AS-20241206152840

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Dec 11, 2024

Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirerment was not met as evidenced by: Based on LPA Jensen's interview with staff and observation of a blank LIC 621 the faciity did not follow it's own policies for safeguarding resident valuables.the state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: An attestation will be sent by email to the Department stating that Maria Araiza will personally label and maintain written logs of resident property effective immmediately. This Plan of Corretion is based on facility staff request. No further action required.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Legal/Non-compliance

An Informal Conference was conducted today, 09/12/24, via Microsoft Teams. The purpose of the Informal Conference was to discuss the facilities non-compliance with Title 22 Regulations. Present at today's Informal Conference were: Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Maja Jensen, Licensee/Administrator Bonnaire Yepez and facility care staff Maria Araiza. The informal conference process was explained during this meeting. The facility has had 9 A type citations over the course of the last year. It was learned that the Licensee is in the process of selling the care home to Maria Araiza. Maria Araiza has an Administrator's certification that is pending with the Department and has submitted an application for a residential care facility for the elderly (RCFE) license to the Centralized Application Bureau (CAB) as of 9/11/24. The following issues were discussed during the informal conference: · Compliance requirements for the proposed change of ownership · Resident Records · Personal Rights · Accountability of the Licensee Licensees stated they will do the following to achieve continued and substantial compliance: · Hire a full time Administrator by 9/16/24 · Submit signed copies of the change in ownership notification given to residents · Submit evidence of TB tests for residents Continued on LIC 809C.... The Licensee was advised that administrative action will be taken if the non-compliance issues persist. The Licensee and the RCFE applicant were advised that the application can be denied for substantial non-compliance. The Department will increase monitoring to at least monthly until the change in ownership occurs or until the facility reaches substantial compliance. A copy of this report was sent to the Licensee for electronic signaturethe state’s words, verbatim · CDSS document, Sep 12, 2024

Type of visit: POC

On 9/11/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a Plan of Correction visit. LPA Jensen met with Maria Araiza and explained the purpose of today's visit. LPA Jensen followed up on a deficiency for a personal rights violation observed on 9/4/24. LPA Jensen interviewed Resident 1 (R1) who confirmed that she has a new wheel chair that fits through the door. R1 also has a podiatry appointment scheduled. The plan of correction has been cleared. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2024

Type of visit: Case Management - Annual Continuation

On 9/11/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a required 1 year annual inspection. LPA Jensen met with Maria Araiza and explained the purpose of today's visit. LPA Jensen advised Maria that the annual fees are due. LPA Jensen reviewed 2 of 2 care staff files. 1 of 2 staff files did not have a health screen. 1 of 2 staff files did not have any training documented since 2023. LPA Jensen reviewed 2 resident files. 2 of 2 files did not have TB tests documented. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Oct 9, 2024

Personnel Requirements - General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by: Based on LPA Jensen's file review, S1 has not had training since 2022. This poses a potential risk to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: Please have all staff members complete required training by POC due date and submit signed documentation as verification that training has been completed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87458 · Plan of correction due date: Sep 12, 2024

a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment...(b) The medical assessment shall include, ...an examination for communicable tuberculosis. This requirement was not met as evidenced by LPA Jensen's review of staff files in which 2 of 2 residents did not have TB tests documented.the state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: Staff called hospice and arranged for TB tests to be completed by tomorrow in the presence of the LPA. No further action required.

Type of visit: Required - 1 Year

On 9/4/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual inspection. LPA Jensen met with care provider Maria Araiza and explained the purpose of today's visit. Maria Araiza advised LPA Jensen that she has submitted an application for licensure in anticpation of a change of ownership. Licensee Bonnaire Yepez has confirmed that she is in the process of transferring the licensure. LPA Jensen toured the grounds and found them to be well maintained with all paths clear of obstruction. LPA Jensen toured the interior and observed there to be adequate lighting and furnishings. There are currently 5 residents with 4 residents in the home and 1 resident in the hospital. The smoke detectors were determined to be in good working order. There are no carbon monoxide detectors in the home. LPA Jensen toured the kitchen and observed insufficient perishable food and non-perishable food. The perishable food was restocked in the presence of LPA Jensen and non-perishable food was ordered on line in the presence of the LPA to be delivered tomorrow. The fire extinguisher was last serviced in 2022 and was out of compliance. A new fire extinguisher was purchased and delivered during the course of this visit. The smoke detectors were observed to be in working order. There are no carbon monoxide detectors according to the care provider and LPA Jensen did not observe any. LPA Jensen Jensen reviewed the Medication Administration Record (MAR) for resident 1 (R1) and saw an ace inhibitor medication listed as a PRN. LPA Jensen checked the label and saw the medication was not a PRN. The medication came in a bubble pack and appeared to be administered on a daily however the number of pills remaining did not align with the dates listed on the Centrally Stored Medication and Destruction Record. The laundry room was inspected and cleaning products were observed that were accessible to residents in care. Various grooming supplies such shampoos, cleansers, wound treatment was also observed in 2 bedrooms to be accessible to residents in care. LPA Jensen conducted an interview with resident 2 (R2) It was learned that R2 has a wheel chair however the wheel chair does not fit through the bedroom door. LPA Jensen also observed that R2 is in need of podiatry care (photo taken). During the course of this visit a home health/social worker (SW1) came to visit R2. LPA Jensen asked SW1 to assist in arranging podiatry care for R2 and to address the need for R2 to have the ability to use her wheel chair. LPA Jensen observed 2 different topical medications in a resident closet for residents that are deceased. LPA reviewed the resident file for R2. The LIC had incomplete sections and a large portion of it was filled out by the resident. The resident was charged a rent increase for a change in condition but there was no change to the needs and service plan. The increase in rate was also not itemized. R2 uses a BIPAP machine and there is no mention of the BIPAP machine on the resident appraisal or needs and service plan. This annual inspection will require a continuation. Deficiencies are being cited and a civil penalty is being assessed. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Sep 5, 2024

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on LPA Jensen's observation and care providers statement that the facility does not have carbon monoxide detectors. This poses an immediate risk to the health safety and personal rights of residents in carethe state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: The Licensee has replaced the fire extinguisher and will purchase and install carbon monoxide detectors by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(26) · Plan of correction due date: Sep 4, 2024

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 was not met as evidenced by: Based on LPA Jensen's observations the facility did not have 2 days worth of perishable foord or 7 days worth of non-perishable foodthe state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: Maria Araiza purchased food and had it delivered in the repsence of the LPA. No further plan of correction is required at this time.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80072(a)(2) · Plan of correction due date: Sep 4, 2024

Personal Rights To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by: Based on an interview with R2 and LPA Jensen's measurement of the bedroom doorway, R2 cannot exit the bedroom in her wheelchair. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: LPA Jensen asked a home health aid/social worker assigned to the resident to assist with residents wheel chair not fitting through doorway during the course of the visit. Licensee will follow up to advise of outcome by 9/9/24.

Type of visit: Case Management - Incident

On 8/1/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management in relation to an incident report received on 7/31/24. LPA Jensen met with Angelica Chicas and explained the purpose of today's visit. Angelica Chicas called Licensee Bonaire Yepez and LPA Jensen spoke to the Licensee by telephone and explained the purpose of today's visit. The facility has a hospice waiver for 6. An incident report was received regarding a resident in care that is on hospice. The facility notified the Department that the responsible party for resident 1 (R1) requested R1 be taken off of hospice in order to be sent to the hospital and would not be returning. LPA Jensen interviewed R1's daughter, R1's son in law and R1's close friend who all stated that R1 is being moved due to concerns at the facility surrounding sanitation and neglect. LPA Jensen inspected the facility and observed cockroaches, spiders and other unidentified insects. LPA Jensen reviewed R1's file and observed R1 was lacking a pre-placement appraisal and resident appraisal or needs and service plan. LPA Jensen reviewed the hospice care plan and observed that the care plan lacked a description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties. LPA Jensen also observed various care notes from the month of July 2024 that were signed by 2 staff members not associated to the facility. It should be noted that the licensee was provided technical assistance by email on personnel requirements, criminal background clearance and transfers on July 19, 2024. LPA Jensen interviewed Staff 1 (S1) who advised that Staff 2 (S2) is in charge and now running the facility. LPA Jensen verified that S2 is not yet associated to the facility. LPA Jensen interviewed S2 who confirmed that she and the licensee have entered in to an agreement for a change in ownership at the beginning of July 2024. On July 19th, 2024, LPA Jensen provided technical assistance to the Licensee informing her that the Department and all residents must receive notification of any intent to sell or transfer ownership of the business. No notification was sent to date. LPA Jensen provided technical assistance on hospice care and reporting requirements. This case management will require additional time to investigate. LPA Jensen left the facility for a meal period at 12:30pm to 1:30pm. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205 · Plan of correction due date: Aug 2, 2024

The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement was not met as evidenced by: Based on Licensee's confirmation that staff were not associated and notice of intent to sell or transfer had not been given despite technical assistance being provided by LPA Jensen on 7/19/2024. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: The Licensee provided notice if intent to sell during the course of this visit as well LIC 9182's for employees needing transfers. The Licensee agrees to provide all residents with notification of the intention to sell by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR80087(a)(1) · Plan of correction due date: Aug 8, 2024

Buildings and Grounds The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by: Based on LPA Jensen's observation of insects on the floor and in the cupboards.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: The Licensee agrees to have a pest control company complete a service by POC due date and agrees to establish bi-monthly pest service.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Aug 2, 2024

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility ... readily available ... to licensing agency staff. This requirement was not met as evidenced by: Based on LPA Jensen's record review, R1 lacked a pre-placement appraisal, needs and service plan and complete hospice care plan. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: The Licensee agrees to submit an attestation that all resident files and hospice care plans are fully updated and complete by 9/2/24.

Type of visit: Case Management - Legal/Non-compliance

An Informal Conference was conducted today, 05/24/24, via Microsoft Teams. The purpose of the Informal Conference was to discuss the facilities non-compliance with Title 22 Regulations. Present at today’s Informal Conference were Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Maja Jensen, and Licensee, Bonaire Yepez. The informal conference process was explained during this meeting. The facility has received 2 type A citations and 7 type B citations within the last 10 months. The Licensee was offered an opportunity to participate in the Department's Technical support Program and accepted. The Licensee indicated that she is in the process of hiring a new Administrator. The Licensee also stated that she is in the process of changing the facility flooring however the renovations are not anticipated to impact clients in care. The Department will conduct a Health and Safety check in approximately 4-6 months to monitor for compliance. No deficiencies were cited as a result of this meeting. An exit interview was conducted by telephone and a copy of this report and appeal rights were provided electronically.the state’s words, verbatim · CDSS document, May 24, 2024

Allegation investigated: Licensee did not provide POA a copy of the signed Admission Agreement

On 4/12/24 at approximately 12pm Licensing Programm Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings related to the above listed allegations. LPA Jensen met with Angela Chicas and explained the purpose of today's visit. On 3/1/24 LPA Jensen interviewed the Licensee by telephone. The Licensee, Bonaire Yepez, confirmed that she did not provide a copy of the Admission Agreement to the resident's Power of Attorney upon signing however she was willing to provide a copy of the agreement at any time after admission upon request. The Licensee/Administrator also stated that she was not aware that providing a copy of the admission agreement was a regulatory requirement. Based on the interview with the Licensee/Administrator the allegation of "Licensee did not provide POA a copy of the signed Admission Agreement" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited pursuant to the the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct Deficienices may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Apr 12, 2024 · control 27-AS-20240223144547

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Apr 17, 2024

Admission Agreements The licensee shall provide a copy of the signed and dated current admission agreemen... immediately upon signing the admission agreement or modification. This requirement was not met based on: the Licensee's own admission that a signed copy was not provided to the resident's responsible party. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2024

Plan of correction: The Licensee agrees to sign an attestation that CCR 87507 has been read, understood and will be complied with in it's entirety and will email teh attestation to maja.jensen@dss.ca.gov by the Plan of Correction due date.

Allegation investigated: Staff did not provide residents authorized person copies of resident's records

On 4/12/24 at approximately 10:45 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unanounced to open a complaint investigation in to the above listed allegation. LPA Jensen met with Angela Chicas who advised the Licensee/Administrator is out of town and unanavailble. Angela Chicas advised she is the designee in the Administrator's absence. LPA requested the records for Resident 1 (R1). LPA Jensen was only provided a hospice binder. LPA Jensen spoke to the Licensee by telephone and she confirmed that only the hospice records are available and the attorney was sent what records were available. Based on an interview with the Licensee all available records sent upon request and the "staff did not provide resident's authorized person copies of resident's records is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preonderance of evidence does not prove it. A seperate case management will be conducted for a lack of required records. An exit interview was conducted and a copy of this report and appeal rights were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 12, 2024 · control 27-AS-20240404104236

Type of visit: Case Management - Deficiencies

On 4/12/24 Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to open a complaint investigation for compliant number 27-AS-20240404104236. LPA Jensen met with Angela Chicas and explained the purpose of the visit. LPA Jensen also spoke to the Licensee/Administrator by phone and explained the visit. While investigating the above listed allegation, it was learned that the facility had accepted a resident (R1) without creating and/or maintaining resident records as required by the California Code of Regulations (CCR) Title 22, Division 6, Section 87506. LPA Jensen asked the Licensee/Administrator asked the Licensee/Administrator which records were required prior to accepting a resident and she stated she was not aware. LPA Jensen reviewed the file for Resident 2 (R2) and observed no pre-placement appraisal and no physician's report (LIC 624). A review of the resident file for R2 revealed that R2 requires assistance for all Activities of daily living and is on hospice. During the course of this visit, a hospice nurse arrived to check on R2. LPA Jensen interviewed the hospice nurse who stated R2 has an unstageable sacrococcyx wound. R2 has at least 2 prohibited health conditions and no documentation was found that describes the type and frequency of the care tasks to be performed by the facility staff. During the course of the investigation for complaint control number 27-AS-20240223144547, the Licensee/Administrator advised she was not aware that a copy of the admission agreement must be provided to the resident or responsible party upon signing. Deficiencies are being cited from CCR, Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. . An exit interview was conducted and a copy of this reportthe state’s words, verbatim · CDSS document, Apr 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Apr 13, 2024

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met based on: Based on the Licensee/Administrator's own admission that facility records were not created upon acceptance of R1 and a lack of required records for R2 based on LPA Jensen's file review. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2024

Plan of correction: The Licensee will send an attestation by email to maja.jensen@dss.ca.gov by 4/13/24 that all current resident files will be reviewed and updated for compliance CCR 87506 by 5/12/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(b)(4) · Plan of correction due date: May 12, 2024

Hospice Care of Terminally Ill Residents A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: ...A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility. This requirement was not met based on LPA Jensen's review of the resident file and lack of a hospice care plan for R2. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2024

Plan of correction: The Licensee agrees to update all current resident files for residents on hospice with a comprehensive plan that is in compliance with CCR 87633 in it's entirety.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: May 12, 2024

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). ... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met based on: The Licensee/Administrator's own admission that she was not aware of requirements surrouding resident records and admission agreements. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2024

Plan of correction: The Licensee/Administrator agrees to complete an additional 5 hours of Administrator training with a focus on hospice care and record keeping.