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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011400061
Report Date: 08/24/2022
Date Signed: 08/24/2022 08:01:19 PM

Substantiated


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
08/17/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220817121529
FACILITY NAME:BETHESDA HOMEFACILITY NUMBER:
011400061
ADMINISTRATOR:DAVID R. MARTINEZFACILITY TYPE:
740
ADDRESS:22427 MONTGOMERYTELEPHONE:
(510) 538-8300
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:28CENSUS: 19DATE:
08/24/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:David Martinez/AdministratorTIME COMPLETED:
08:00 PM
ALLEGATION(S):
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-Staff interfere with residents' mail.

-Staff do not properly store residents' records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with staff, Infection Preventionist LVN Cynthia Angeles, Director of Nursing Yeromnesh "Merry" Tesema, and Rosario "Charo" Quispe Figueroa, and informed the purpose of visit. David Martinez, administrator, arrived after about an hour and a half.

LPA conducted inspection and interview.

Allegation: Staff interfere with resident's mail.
LPA interviewed and David Martinez, administrator, stated that when staff in-charge of delivering mail was out and another staff delivered one of the resident's (R1) mail to the facility's Business Office instead to R1 . The staff at the Business Office opened R1's mail. On this day upon arrival to the facilty, LPA observed mail of some of the residents in unlocked office.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
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 4
Control Number 15-AS-20220817121529
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: 08/24/2022
NARRATIVE
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Allegation: Facility does not properly store residents' records.
LPA conducted inspection with Cynthia Angeles, Yeromnesh "Merry" Tesema, and Rosario "Charo" Quispe Figueroa, and observed residents' files stored in an open shelves readily accessible to anyone.

Based on interview and inspection, the two allegations are closed as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with David Martinez. David has to leave and authorized Cynthia to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20220817121529
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2022
Section Cited
HSC
87468.1(a)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(15) To send and receive unopened correspondence in a prompt manner.

-This requirement is not met as evidenced by:
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Administrator to do the following:.
1. Come up with a plan to ensure the residents' mails are unopened and given in a timely manner.
2. In-service the staff.
Proof to bve submitted by 9/07/2022.
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-Based on interview and observation, the licensee did not comply with the section above for R1's mail opened by staff and residents' mail left in the unlocked office which posed personal rights risks to persons in care.
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Type B
09/07/2022
Section Cited
CCR
1569.269(a)(3)
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ยง1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(3) To confidential treatment of their records and personal information and to approve their release, except as authorized by law.

-This requirement is not met as evidenced by:
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Admiistrator stated he'll have the resident's files temporarily stored in the med room with lock until doors with lock are installed in the shelves. Picture to be submitted by 9/07/2022.
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-Based on inspection, the licensee did not comply with the section above for residents' files kept in open shelves readily accessible to anyone.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4