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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400061
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:44:08 PM

Document Has Been Signed on 04/06/2022 04:44 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:FULLER, DOUGLAS D.FACILITY TYPE:
740
ADDRESS:22427 MONTGOMERYTELEPHONE:
(510) 538-8300
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 28CENSUS: 14DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH: Administrator Douglas FullerTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Administrator Douglas Fuller and Director of Nurses Cita De Jesus and informed the purpose of visit. LPA also met with Housekeeping Supervisor Rosario Figueroa and LVN-Director of Staff Development Cynthia Angeles.

Facility has an approved LIC808 Mitigation Plan. Staff were fit tested for N95 respirators on March 2021. Facility is to recertify staff for N95 fit testing.

LPA inspected the facility inside out with Cita De Jesus and Rosario Figueroa and later joined by Douglas Fuller. The assisted living side of the facility has five buildings namely the Azalea Cottage, Garden Cottage, West Wing, Peralta Cottage and Mission Cottage. LPA randomly selected for inspection seven (7) residents rooms. LPA also inspected the living room, dining area, kitchen, bathrooms, toilets, shower room and yard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. Facility uses mechanical means of cleaning/rinsing dishes and utensils. Lamp and lights were present in all rooms. Toilet, hand washing and bathing areas were observed in operating conditions.

LPA observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch temperature probe. Surgical masks and disposable gloves are readily available at the screening station. Checking of visitor's temperature and symptom checks are done at entry for all staff and visitors. Residents are screened for COVID-19 symptoms and temperature checked daily. Facility keeps record of proof of vaccination of visitors and antigen test kits are readily available at the screening station. Trash bins were observed with foot pedal operated lids.

.......continued on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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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: 04/06/2022
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Facility has working carbon monoxide and smoke detectors. Hot water temperature in one of the toilets was tested and measured at 120 degrees Fahrenheit. LPA checked one of the fire extinguishers and observed fully charge with tag showed serviced February 10, 2022.

At 1:13 pm, LA observed gallon of peritoneal cleanser in one of the toilets/restrooms' unlocked cabinet.

On this same day, LPA obtained copy of proof of $3M liability insurance coverage.

LPA requested for copies of the following updated documents to be submitted to Community Care Licensing (CCL) by April 20, 2022:
1. LIC500 Personnel Report
2. LIC610E Emergency Disaster Plan

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Douglas Fuller.

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

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/06/2022 04:44 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/06/2022 at 03:32 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: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)

87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Peritoneal cleanser was observed unlocked in a cabinet in one of the residents' toilets which poses an immediate safety risk to persons in care.
POC Due Date: 04/07/2022
Plan of Correction
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Staff locked the item while LPA is at the facility,
In addition, administrator to in-service the staff and submit proof by 4/07/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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