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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400061
Report Date: 02/04/2022
Date Signed: 02/04/2022 01:30:13 PM

Document Has Been Signed on 02/04/2022 01:30 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BETHESDA HOMEFACILITY NUMBER:
011400061
ADMINISTRATOR:FULLER, DOUGLAS D.FACILITY TYPE:
740
ADDRESS:22427 MONTGOMERYTELEPHONE:
(510) 538-8300
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 28CENSUS: 12DATE:
02/04/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Douglas Fuller/Executive Director and
Director of Nurses Cita De Jesus		TIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a complaint (Control # 5-AS-20220203111212. LPA met with Executive Director (ED) Douglas Fuller and Director of Nurses (DON) Cita De Jesus and informed the purpose of visit.

The community consisted on Independent Living (IL), Assisted Living (AL) and Skilled Nursing Facility (SNF). AL and SNF are housed in the same building while IL are the cottages. Dining area is shared by AL and SNF.

LPA inspected the AL section of the building with with ED and DON. LPA inspected the living room area, salon/staff room, 3 bathrooms, and randomly selected 7 rooms for inspection which included 3 vacant rooms. The salon was closed and staff had to key in the code to access this room. Facility has sufficient lighting. Hallways and passageways were observed free of obstructions.

No deficiency cited during this visit.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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