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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200973
Report Date: 05/15/2025
Date Signed: 05/15/2025 04:46:12 PM

Substantiated


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
01/13/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250113123656
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: 34DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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On 5/15/2025 at 12:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPA met with Manager, Rachell Paniagua and explained the purpose of the visit.

During the course of investigation, LPA interviewed 5 staff and complainant. LPA obtained and reviewed documents including staff roster with contact information, MAR (medication administration records), medication list, medication release form, admission agreement, physician's report, preplacement appraisal, care plan, emergency information, and refund invoice. LPA observed the 3rd level's floor was in disrepair. The flooring were lifted and some areas were taped down.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted with Rachell Paniagua. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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 4
Control Number 15-AS-20250113123656
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2025
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by:
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Manager stated the 3rd level's floor was installed about 2 weeks ago. LPA observed the flooring on the 3rd level was completely replaced.
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Based on observation, licensee did not comply with the section cited above by having the 3rd level flooring in disrepair which poses a potential health and safety risk to the persons in care.
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Deficiency cleared.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
01/13/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250113123656

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: 34DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff mismanaged resident's medications.
Licensee did not ensure that resident was provided the care and supervision as promised.
Facility failed to provide refund to responsible party.
INVESTIGATION FINDINGS:
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On 5/15/2025 at 12:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegations above. LPA met with Manager, Rachell Paniagua and explained the purpose of the visit.

During the course of investigation, LPA interviewed 5 staff and complainant. LPA obtained and reviewed documents including staff roster with contact information, MAR (medication administration records), medication list, medication release form, admission agreement, physician's report, preplacement appraisal, care plan, emergency information, and refund invoice.

Staff mismanaged resident's medications.
R1's MAR revealed that R1 was given medications according to doctor's orders. Record reviews indicated there was a medication release form signed by R1's family and facility staff when R1 left the facility.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20250113123656
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: 05/15/2025
NARRATIVE
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Licensee did not ensure that resident was provided the care and supervision as promised.
Interview with complainant indicated that the facility staff informed R1's family there was a 3:1 residents to staff ratio, but later observed the ratio was 15 residents to 1 staff. Interview with staff revealed residents have call buttons and response time is around 5-15 minutes. S2 stated there was no staff ratios discussed with R1's family and no promises were made.

Facility failed to provide refund to responsible party.
R1's admission agreement stated "no part of any monthly rate payment will be refunded..." LPA observed the facility issued a refund of $4500 to R1.

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

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

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4