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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200309
Report Date: 08/11/2022
Date Signed: 08/11/2022 10:57:21 AM

Document Has Been Signed on 08/11/2022 10:57 AM - 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 HOMEFACILITY NUMBER:
079200309
ADMINISTRATOR:NAGY, ARPADFACILITY TYPE:
740
ADDRESS:2201 ROCKNE DRIVETELEPHONE:
(925) 640-6403
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: DATE:
08/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:TIME COMPLETED:
11:10 AM
NARRATIVE
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On 08/11/2022 at 9:58 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger conduct a Case Management. LPA met with Telesha Clarke, Administrator.

While LPA conducted a complaint investigation (15-AS-20220809095150) on 08/11/2022, LPA observed the facility did not have the resident records at the facility.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/11/2022 10:57 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 08/11/2022 at 09:59 AM
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
FACILITY NUMBER: 079200309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2022
Section Cited
CCR
87506(a)

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The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
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Administrator agreed to put together and complete files for all residents and submit a copy of all documentation to CCLD by POC
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Based on observation and record review, Licensee did not comply with the regulations cited above by not having 4 out of 6 resident records at the facility
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
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