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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011400061
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:53:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220203111212
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: 14DATE:
04/06/2022
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Administrator Douglas FullerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Conduct Inimical: Staff (S1) sexually abused and exposed his private parts to resident (R1).
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Douglas Fuller, administrator, and informed the purpose of visit.

It was alleged that staff (S1) exposed his private parts to R1 and sexually abused R1 by grabbing R1’s breast. Law enforcement was also involved in the investigation.

The Department obtained copies of staff and resident rosters, police report, facility documentation of the allegation and events, and R1’s medication lists and Psychopharmacologic Drug Summary Sheet. The Department conducted interviews.


......continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20220203111212
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BETHESDA HOME
FACILITY NUMBER: 011400061
VISIT DATE: 04/06/2022
NARRATIVE
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S1 is a staff member in both the Bethesda Skilled Nursing Facility (SNF) and the licensed Bethesda Independent Living and Assisted Living facilities. On 01/20/2022, R1, a resident in the SNF, called R1’s counselor and disclosed that S1 had exposed his private parts to R1 and touched R1’s breast. R1 indicated that S1 walked into R1’s room, unzipped his pants and exposed his private parts. R1 told S1 to leave and S1 did. On multiple occasions R1 would reportedly enter R1’s room, and grab R1’s right breast. S1 denied the allegations and stated he was never inappropriate with R1. Staff (S2) indicated that when R1 was admitted, R1 has medication that has a side effect of dream disorder. R1 was assessed by a SNF doctor and placed on anti-psychotics following the allegation. Facility staff (S3 and S4) for both the licensed and SNF facilities believed R1 was hallucinating or having dreams about the incidents. R1 was interviewed and was consistent in disclosure and adamant that S1 assaulted R1. The Police Department took a report but closed the case as unfounded after R1’s daughters stated they believed R1 was hallucinating.

Based on information obtained during the course of investigation, there’s not enough preponderance of evidence to prove that a violation occurred. Therefore, the allegation of conduct inimical is closed as unsubstantiated. No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2