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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200973
Report Date: 11/11/2022
Date Signed: 11/11/2022 03:14:11 PM

Document Has Been Signed on 11/11/2022 03:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BETHANY HOME SENIOR LIVING, LLCFACILITY NUMBER:
019200973
ADMINISTRATOR:NAGY, ARPADFACILITY TYPE:
740
ADDRESS:3322 EAST AVE.TELEPHONE:
(925) 443-6822
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 58CENSUS: 31DATE:
11/11/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:
Rachell Paniagua/Manager		TIME COMPLETED:
03:10 PM
NARRATIVE
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On November 11, 2022, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20221107163346). LPA met with Rachell Paniagua, manager, and informed the reason for visit.

LPA toured the facility including but not limited to common areas, ensuite and common bathrooms, dining rooms on the second and third floor. LPA randomly selected total of 5 bedrooms on the first, second and third floor. LPA checked and observed the facility's room temperature at 71 degrees Fahrenheit. Laundry room was observed locked. LPA observed no hand washing posters on some of the bathrooms/lavatories.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Rachell Paniagua.

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: 11/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/11/2022 03:14 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/11/2022 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BETHANY HOME SENIOR LIVING, LLC
FACILITY NUMBER: 019200973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/12/2022
Section Cited
ILS
87465(h)(1)(C)

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87465 Incidental Medical and Dental Care (h) (1) Medications shall be centrally stored under the following circumstances:(C)Because of potential dangers related to the medication itself, or due to physical arrangements in the facility ....or Department to be a safety hazard to others
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The manager locked the items,
In addition, an in-service training will be conducted and proof to be submitted by 11/12/2022.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above. Gas relief medication and Magnesium supplement were observed in the closet in resident's bedroom. which pose immediate health risks to persons in care.
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Type A
11/12/2022
Section Cited
CCR87705(f)

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)

-This requirement is not met as evidenced by.
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The manager locked the item.
In addition, an in-service training will be conducted and copy training topic with attendees signatures to be submitted by 11/12/2022.
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-Based on observation, the licensee did not comply with the section above. Razor was observed unlocked in one of the bedrooms on the second floor which poses immediate safety risk to persons in care.
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2