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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400061
Report Date: 02/17/2023
Date Signed: 02/17/2023 06:26:43 PM

Document Has Been Signed on 02/17/2023 06:26 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:DAVID R. MARTINEZFACILITY TYPE:
740
ADDRESS:22427 MONTGOMERYTELEPHONE:
(510) 538-8300
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 28CENSUS: 18DATE:
02/17/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:20 PM
MET WITH:Cynthia Angeles/LVN-Infection PreventionistTIME COMPLETED:
06:30 PM
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On this day, February 17, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20230215113247). LPA met with Cynthia Angeles, facility LVN-Infection Preventionist, and informed the reason for visit.

LPA toured the facility including but not limited to common areas, dining rooms, kitchen, living room, and bathrooms. LPA observed the salon locked. Some residents were observed in the dining rooms eating dinner, LPA randomly selected 5 residents rooms in the main building and 1 room in the Assisted Living cottage.

No hazards observed, and no deficiency cited during today's visit.

Exit interview conducted and copy of this report conducted.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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