<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400061
Report Date: 02/28/2023
Date Signed: 02/28/2023 06:14:03 PM

Document Has Been Signed on 02/28/2023 06:14 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: 16DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH: Infection Preventionist LVN Cynthia Angeles
and Supervisor Rosario "Charo" Quispe Figueroat.		TIME COMPLETED:
06:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with met with staff, Infection Preventionist LVN Cynthia Angeles and AL Supervisor Rosario "Charo" Quispe Figueroa, and informed the purpose of visit.

Facility has an approved LIC808 Mitigation Plan. Facility has not submitted the LIC9282 Infection Control Plan.

LPA toured the facility inside out with Cynthia Angeles and Rosario Figueroa. LPA inspected the living room, dining area, kitchen, hallways, 3 common bathrooms. LPA randomly selected 6 residents' rooms for inspection. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. Central storage for medication and salon/staff lounge room were observed locked.

Facility has screening station with hand sanitizer, no touch temperature probe.. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs were sufficient.. Facility has antigen test kits readily available. COVID-19 signages were observed all throughout the facility. Bathroom lavatories were observed with liquid soap and paper towels in dispensers for hand drying. Trash cans were observed with no touch lids.

Fire extinguishers checked, observed fully charge with tags showed serviced February 17, 2023. Hot water temperature in one of the common bathrooms was tested and measured at 119 degrees Fahrenheit.

.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 02/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Adminstrator to submit the following by March 14, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. Proof of $3M liability insurance.
5. Staff's current N95 fit testing records/certificates
6. LC9282 Infection Control Plan

No deficiency observed during today's visit.

Exit interview conducted and and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2