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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400061
Report Date: 05/17/2024
Date Signed: 05/17/2024 05:33:14 PM

Document Has Been Signed on 05/17/2024 05:33 PM - 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:BETHESDA HOMEFACILITY NUMBER:
011400061
ADMINISTRATOR/
DIRECTOR:		DAVID R. MARTINEZFACILITY TYPE:
740
ADDRESS:22427 MONTGOMERYTELEPHONE:
(510) 538-8300
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 28CENSUS: 14DATE:
05/17/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Roselyn Chand/Acting Administrator TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On this day, May 17, 2024, Licensing Program Analyst (LPA) Delmundo conducted unannounced visit to continue the annual inspection that was started on May 1, 2024. LPA met with Roselyn Chand, acting administrator, and informed the reason for visit.

LPA reviewed 5 staff and 5 residents files and interviewed 1 staff. Medications were checked and compared with doctor's order of medications and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.

LPA observed the following:
-at 12:10 pm, staff (S1) has no 4 hours required training on file on postural support/restricted health conditions/hospice care.
-at 12:30 pm, S3 is CPR/AED certified but no First Aid certificate on file.
-at 1:40 pm, S4 is CPR/AED certified but no First Aid certificate on file.
-at 1:25 pm, resident's (R2) LIC602A indicated non-ambulatory, and R2 needs cane to move around and about but the facility is not licensed and not fire cleared for non-ambulatory
-at 3:00 pm, resident (R5)'s doctor's order 1/16/24 for 1 of medications is 50 mg, 2x daily but the label on the medication filled on 4/18/24 showed 1 tablet daily.


....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BETHESDA HOME
FACILITY NUMBER: 011400061
VISIT DATE: 05/17/2024
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 87202(a)(1). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalty.

Deficiencies and plan, and proof of corrections were discussed with the acting administrator.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/17/2024 05:33 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/17/2024 at 04:02 PM
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: BETHESDA HOME
FACILITY NUMBER: 011400061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in S1 has no 4 hours required training on file on postural support/restricted health conditions/hospice care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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2
3
4
Administrator to have the staff complete the training and submit proof by 5/31/24.
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in S3 and S4 not First Aid certified which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
1
2
3
4
Admiinistrator to have the staff register for training and submit copies of certificates by 5/31/24.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/17/2024 05:33 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/17/2024 at 05:04 PM
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: BETHESDA HOME
FACILITY NUMBER: 011400061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87564(h)(4)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in medication label of 1 of R5’s medication does not match the doctor’s order which poses a potential health and/or personal rights risks to person in care.
POC Due Date: 05/31/2024
Plan of Correction
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2
3
4
Administrator to obtain correct label and submit proof by 5/31/24.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/17/2024 05:33 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/17/2024 at 05:10 PM
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: BETHESDA HOME
FACILITY NUMBER: 011400061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(1) Nonambulatory persons.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation andvrecord review, the licensee did not comply with the section cited above in R2 being non-ambulatory and the facility has no fire clearance nor licensed for non-ambulatory which poses an immediate safety risk to person in care.
A $500.00 civil penalty is assessed.
POC Due Date: 05/18/2024
Plan of Correction
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Administrator to issue an eviction and submit copy by 5/18/24.
Section Cited
Deficient Practice Statement
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2
3
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POC Due Date:
Plan of Correction
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4
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


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