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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001208
Report Date: 08/10/2021
Date Signed: 08/10/2021 04:00:02 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2021 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210506085518
FACILITY NAME:BETHESDAFACILITY NUMBER:
347001208
ADMINISTRATOR:VICTOR BURACHEKFACILITY TYPE:
740
ADDRESS:8312 BRAMBLE TREE WAYTELEPHONE:
(916) 723-4960
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 6DATE:
08/10/2021
UNANNOUNCEDTIME BEGAN:
03:05 AM
MET WITH:Staff- Vera JitariTIME COMPLETED:
04:05 AM
ALLEGATION(S):
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Allegation is unlawful eviction.
INVESTIGATION FINDINGS:
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On 08/10/2021 at 3:05 PM , Licensing Program Analysts (LPAs) Sarena Keosavang and Michael Hood arrived at the facility to deliver a complaint finding Community Care Licensing (CCL) received on 05/06/2020. LPA Keosavang requested for staff to notified Administrator that LPAs are present at the facility to deliver final finding. LPA spoke with Administrator, Victoria Cardona, and explained the purpose of the visit. Administrator is unable to meet LPAs at the facility. LPAs went over complaint findings via telephone. Administrator gave staff permission to sign report.

Throughout the course of the complaint investigation, the Department obtained documents such as resident’s (R1) Physician’s Report, Admission Agreement, Functional Capability Assessment, Appraisal, Consent for Medical Emergency Form, Identification and Emergency Information Form, Centrally Stored Medication, Medical Documents, and Unusual Incident Report.

The Department received an interview statement from the Licensee regarding the allegation above. Licensee stated he was contacted by a placement agency for temporary housing for R1.

********** Continue on page LIC 9099-C **************
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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 25-AS-20210506085518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: BETHESDA
FACILITY NUMBER: 347001208
VISIT DATE: 08/10/2021
NARRATIVE
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Licensee stated, while R1 was staying at the facility for about 4-5 months, the facility did not receive any form of payment for R1. Licensee stated he had reached out to the placement agency for R1 and requested payment. Licensee stated he had received a payment from the placement agency, however, it was not in the full amount. Licensee stated he had contacted R1’s POA regarding payments and moving R1 to another facility.

The Department requested for an eviction letter for review. Licensee stated he did not submit an eviction letter to CCL or gave notice to R1 or R1’s POA. Licensee stated all communication with R1’s POA was verbal. Per facility’s eviction policy, the agreement must specify that a written notice that includes specific facts concerning the date, place, witnesses, and circumstances for eviction will be provided to the resident. Specific conditions under which a resident may be evicted must be worded exactly as written in the applicable law or regulations. “The licensee may, upon 30 days written notice to the resident, evict the resident for one or more of the following reasons.”

An Unusual Incident Report was submitted to CCL. On 05/03/2020, R1 complained of pain on wrist in both hands and was taken to Kaiser Morse ER by Licensee. Licensee stated he had spoken to the Physician that was caring for R1 and indicated that he did not have the resources to care for R1 anymore. Licensee stated the Physician told Licensee that the hospital will place R1 in a Nursing Home. Licensee stated, “Based on his words, I left.” After Licensee had left Kaiser Morse ER for about 30 minutes, Licensee received a call from Kaiser discharge planner to make arrangement to have R1 picked up from the hospital. Licensee explained to Kaiser discharge planner that the Physician will place R1 in a nursing home due to lack of resources. Kaiser discharge nurse notified Licensee what he was doing is considered abandonment. Licensee stated he would only agree to take R1 back to the facility if they would pay him. The Department asked Licensee for clarification from Licensee that R1 did not return to the facility. Licensee stated R1 was not discharged back to the facility and that R1’s POA picked up R1’s belongings.

While R1 failed to pay for services provided, facility did not provide a 30-day notice.

Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted, and a copy of the report was left at the facility.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20210506085518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BETHESDA
FACILITY NUMBER: 347001208
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2021
Section Cited
CCR
87224(a)
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87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement is not met as evidenced by:
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Licensee agrees to write a statement of understanding regarding regulation 87224(a) and submit to CCLD by POC due date.
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 Based on interviews, facility did not ensure that R1 was evicted with a written 30-day notice, which poses an immediate health, safety, and personal rights risk to the residents 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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC9099 (FAS) - (06/04)
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