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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247200745
Report Date: 02/11/2021
Date Signed: 04/05/2021 08:41:42 AM

Document Has Been Signed on 04/05/2021 08:41 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:NEW BETHANYFACILITY NUMBER:
247200745
ADMINISTRATOR:FONSECA, JULIAFACILITY TYPE:
740
ADDRESS:1441 BERKELEY DRIVETELEPHONE:
(209) 827-8933
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY: 76CENSUS: 46DATE:
02/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Julia Fonseca-AdministratorTIME COMPLETED:
11:30 AM
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On this date, Licensing Program Analyst (LPA) David Ayers contacted the facility to conduct a Case Management visit via telephone due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call with Administrator Julia Donseca and Director Lucinda Fonseca.

The Purpose of this visit was to address a deficiency which was discovered during the course of a complaint investigation. During the investigation, it was found that the facility retained a resident, Resident 1(R1), who had prohibited health conditions needing 24 hours skilled nursing care and was beyond the level of care for this facility.

See attached 809D for deficiency cited in accordance with the California Code of Regulations, Title 22. A copy of this report and appeal rights were provided to the Licensee via email and an electronic read receipt confirms receiving these documents.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2021
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 04/05/2021 08:41 AM - It Cannot Be Edited


Created By: David Ayers On 02/11/2021 at 08:40 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW BETHANY
FACILITY NUMBER: 247200745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2021
Section Cited
CCR
87455(c)(2)

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87455 Acceptance and Retention Limitations: (c) No resident shall be accepted or retained if any of the following apply: (2) The resident requires 24-hour, skilled nursing or intermediate care...This requirement was not met as evidenced by:
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Licensee is to submit a plan to ensure only residents who are within the limits of the facility license are accepted and retained in the facility.
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R1 was admitted to the hospital from the facility on 10/23/2020 with multiple stage 3 and 4 pressure injuries and severe malnutrition. Facility staff stated that R1 required a higher level of 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:Andy Xiong
LICENSING EVALUATOR NAME:David Ayers
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2021


LIC809 (FAS) - (06/04)
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