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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011400061
Report Date: 08/15/2025
Date Signed: 08/15/2025 01:08:13 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
08/08/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250808133020
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:
08/15/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Leatrice Ayala/StaffTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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-Staff observed being rough to the resident (R1).

-Staff do not feed resident (R1) sufficiently resulting to weight loss.
INVESTIGATION FINDINGS:
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On this day, August 15, 2025, at 11:45 am, Licensing Program Analyst (Delmundo) arrived unannounced to investigate the above allegations, and met with staff, Leatrice Ayala. LPA called and spoke over the phone with Roselyn Chand, administrator (ADM), and informed the reason the visit. ADM authorized Leatrice Ayala to sign and receive this report.

During the course of investigation, LPA obtain copy of resident roster and staff schedule. LPA also interviewed R1's family member (FM) on 8/11/25 and staff (S2, ADM) on this day, 8/15/25.

FM stated R1 is at the Skilled Nursing (SNF) section and was never admitted to the Assisted Living (AL) side of Bethesda.

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

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
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-20250808133020
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: 08/15/2025
NARRATIVE
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ADM stated staff, S1 and S2, worked in SNF and never worked in AL. S3 stated she has never worked with S1 and S2. Review of staff schedule showed S1 and S2 not listed.

Based on records review and interviews, the allegations of staff observed being rough to R1 and staff do not feed resident R1 sufficiently resulting to weight loss are closed as unfounded due to R1 is a resident of facility’s SNF unit which is not under the jurisdiction of the Department and the two staff never worked in the AL. Therefore, the complaint is dismissed.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2