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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011400061
Report Date: 07/16/2025
Date Signed: 07/16/2025 05:29:05 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
07/10/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250710162549
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: 18DATE:
07/16/2025
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Joan Acob/Staff TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not take steps to prevent the spread of a communicable disease.
INVESTIGATION FINDINGS:
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On this day, July 16, 2025, at 3:20 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation, and met with Joan Acob, staff. LPA called and left message on Roselyn Chand's, administrator (ADM) voicemail and informed of the reason of LPA's visit.

It was alleged that there's acute respiratory illness outbreak/multiple pneumonia cases and 1 related death in the facility.

LPA obtained copies of resident roster and staff schedule. LPA reviewed and obtained copies of residents' (R1 and R2) After Visit Summary and interviewed staff (S1, S2).


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

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
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-20250710162549
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: 07/16/2025
NARRATIVE
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One of the staff interviewed stated the facility has 2 separate cases of pneumonia and the residents are now back to the facility and doing well. Review of After Visit Summary showed R1 was sent out in June 2025 and R2 on July 2025.

Both staff stated the facility is observing universal precautions, doing disinfecting every shift and wearing masks when residents are coughing. Both of them stated there's no outbreak of communicable disease.

Based on information gathered, there is not a preponderance of evidence to prove that a violation occurred, therefore, the allegation 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: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2