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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200973
Report Date: 08/03/2023
Date Signed: 08/03/2023 06:47:11 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
08/30/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220830163946
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: 37DATE:
08/03/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Residents sustained injuries while in care
Unqualified staff providing care to residents
Staff did not receive on the job training
Staff did not prevent resident from engaging in dangerous activities
Staff did not prevent residents from wandering from the facility
Staff did not check on residents in a timely manner
INVESTIGATION FINDINGS:
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On 8/3/2023 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Manager, Rachell Paniagua.

During the course of investigation, the Department and LPA conducted interviews with staff, residents, witnesses, and complainant. LPA also obtained and reviewed documents including: physician's report, care plan, incident reports, emergency information, facility notes, hospice records, and staff training.

Residents sustained injuries while in care
Interview with staff revealed that R2 had two falls in August and September of 2022 in which R2 sustained injuries on head, nose, and forearm. However, staff contacted Hospice nurse to evaluate R2 after each fall.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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-20220830163946
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: BETHANY HOME SENIOR LIVING, LLC
FACILITY NUMBER: 019200973
VISIT DATE: 08/03/2023
NARRATIVE
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Unqualified staff providing care to residents
Staff did not receive on the job training
LPA reviewed a sample of staff training for year 2022 and observed that staff have initial and/or annual training including dementia, medication administration, and caregiver shadowing.

Staff did not prevent resident from engaging in dangerous activities
Interview with staff indicated there was no residents that left the facility and climb on the roof in summer of 2022. Staff stated that R5 attempted to climb out of the bedroom window from the second floor last year, but staff was able to intervene and prevented R5 from climbing out of the window. Facility windows have window screens.

Staff did not prevent residents from wandering from the facility
Interview with residents and staff indicated that no resident wandered outside of the facility and was found on the street in summer of 2022. Staff stated that a resident wandered outside the building, but staff followed the resident and redirected them back inside the facility.

Staff did not check on residents in a timely manner
Interview with staff revealed that residents are checked every 2 hours for incontinence care. Staff stated that residents have pendents and response time is 5-10 minutes.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
08/30/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220830163946

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: 37DATE:
08/03/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained a fracture while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/3/2023 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Manager, Rachell Paniagua.

During the course of the investigation, the Department conducted interviews with staff, residents, and witness. Resident’s physician's report, care plan, incident reports, emergency information, facility notes, and hospice records were obtained and reviewed. Interview with staff indicated that R2 had two falls that occurred in August and September of 2022. According to hospice records, R2 sustained a laceration on upper anterior dorsal head and nose. However, there was no indication that R2 sustained a fracture during the fall. Interview with witness revealed that R2 always tries to get up. Staff contacted hospice after each of the falls to evaluate R2.

This agency has investigated the complaint on the above allegation. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3