011400061-5-17-2024-15-AS-BFOG-D5HTTW-20240522150124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011400061
Report Date: 05/17/2024
Date Signed: 05/17/2024 05:44:33 PM

Unfounded

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 HOME		FACILITY NUMBER:	011400061
ADMINISTRATOR:	DAVID R. MARTINEZ		FACILITY TYPE:	740
ADDRESS:	22427 MONTGOMERY		TELEPHONE:	(510) 538-8300
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	28	CENSUS: 14	DATE:	05/17/2024
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Roselyn Chand/Acting Administrator		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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-Facility does not meet residents' dietary needs.

-Facility's alarm system in disrepair.

-Staff do not answer residents' call buttons in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegation and close the complaint. LPA met with Roselyn Chand, acting administrator, and informed the reason for visit.

During the course of investigation, LPA obtained copies of resident roster, staff schedule and menus. LPA conducted inspection on 8/24/22 and 5/01/24 and interviewed previous administrator, David Martinez, on 8/24/22 and 3 residents on 5/01/24.

Allegation: Facility does not meet residents’ dietary needs.
Reporting party (RP) stated the staff serve residents ‘mush’ and do not serve fresh fruits or vegetables. It was further alleged that residents are served canned foods or frozen foods.

....continued 0n 9099C (apge 2)

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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 3

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: 05/17/2024

NARRATIVE

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Page 2

On 8/24/22 and 5/01/24, LPA inspected the food supplies which were observed of different varieties. LPA observed fresh fruits and fresh meat such as pork, beef, and packages of ground beef. On 8/24/22, LPA obtained copies of menus and the food prepared by kitchen staff for dinner for that day was observed consistent with what was listed on the menu. On 5/01/24, LPA observed different varieties of food supplies including but not limited to fresh pork and beef, vegetables, and fresh cantaloupes. All 3 residents interviewed stated they are served different varieties and fresh fruits. Based on information gathered, the allegation is unfounded.

Allegation: Facility alarm system in disrepair.
It was alleged that the facility’s alarm system did not work.

On 8/18/22, LPA spoke and verified with RP the alarm system RP was referring during the complaint intake. RP stated the facility has fire alarm and smoke alarm that do not go off. RP further stated that the Independent Living (IL) has smoke alarm and that there's no notification system on the IL if something is happening on the Assisted Living (AL) and Skilled Nursing (SNF).

LPA conducted inspection on 8/24/22, and interviewed previous administrator, David Martinez, on 8/24/22 and 3 residents on 5/01/24.

On 8/24/22, LPA tested the smoke and carbon monoxide detectors. Previous administrator stated all the alarms were working including the fire alarm and wander guards for the SNF were working.

Based on inspection, interviews and RP’s statement, and that the Department does have jurisdiction on IL and SNF, the allegation is closed as unfounded.

.....continued on 900c (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 05/17/2024

NARRATIVE

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Allegation: Staff do not answer residents' call buttons in a timely manner.
It was alleged that staff do not answer residents' call buttons in a timely manner and that sometime in 8/2022, the residents’ call lights were not working. It was further alleged that residents scream for assistance however, staff do not assist the residents.

On 8/18/22, LPA spoke with RP who stated the call buttons/lights were the ones on SNF that go off frequently and the staff won’t respond.

On 8/24/22, LPA interviewed previous administrator, David Martinez, who stated when resident in AL main building west wing area pressed their call buttons, calls are transmitted to the pad on the wall in the main building. The pendant call that goes to the computer is from the Independent Living Cottages. LPA requested S1 and S2 to press the call buttons from residents rooms in AL west wing area and LPA observed the signals were transmitted to the pad.

On 5/01/24, LPA interviewed 3 residents, of which one is in the cottage and 2 are in the AL main building rooms. All 3 stated staff come and assist when they call for help.

Based on inspection, observation and interviews, the allegation is closed as unfounded.

A finding that a complaint is unfounded means that the allegations are false, could not have happened, and/or are without a reasonable basis.

No deficiency cited.

Exit interview conducted and copy of this report provided to the acting administrator.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

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