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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011405838
Report Date: 09/22/2023
Date Signed: 09/22/2023 09:44:41 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2023 and conducted by Evaluator Liridon Fici
COMPLAINT CONTROL NUMBER: 15-AS-20230404103125
FACILITY NAME:BETHESDA LUTHERAN COMMUNITIES-MOWRYFACILITY NUMBER:
011405838
ADMINISTRATOR:AVALON HENDERICKSFACILITY TYPE:
735
ADDRESS:1335 MOWRY AVETELEPHONE:
(510) 505-1245
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:12CENSUS: 11DATE:
09/22/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Fidel De Castro, Lead staffTIME COMPLETED:
09:55 AM
ALLEGATION(S):
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Illegal Eviction
INVESTIGATION FINDINGS:
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On 9/22/2023, at 9:15AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a subsequent complaint investigation visit and to deliver findings on the above allegation. LPA met with Fidel De Castro, Lead staff, and explained the purpose of visit.

During the course of the investigation, LPA interviewed S1 and S2 and collected the following documents: eviction notice, current needs and services plan, quarterly reports, physicians report, and progress notes (March and April 2023).




Continue on Lic9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 15-AS-20230404103125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BETHESDA LUTHERAN COMMUNITIES-MOWRY
FACILITY NUMBER: 011405838
VISIT DATE: 09/22/2023
NARRATIVE
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It was alleged that; an illegal eviction was given to client and clients authorized representative. Based on interviews with S1 and S2, and record review conducted. S1 composed an eviction notice on Friday, March 31, 2023, and gave an eviction notice to the client and the client’s authorized representative on Tuesday, April 3, 2023. Prior to submitting an eviction notice, S1 conducted a meeting with RCEB on Tuesday, March 21, 2023, stating that C1 is in need of a higher-level of care and the facility can not meet C1's care needs any longer; C1’s updated Individual support plan (ISP) dated January 26, 2023, indicated C1’s change of condition. It was indicated in the C1's nursing assessment that a one on one is recommended by RCEB clinical team and that RCEB is able to fund a one on one for the C1, however, the facility does not have staffing for one-on-one care at the moment. S1 stated that C1 needs prompting daily for ADLs and needs to supervise C1 more frequently throughout the day. S1 stated that C1 wonders and staff needs to monitor C1 on a daily basis. S2 stated that C1 needs daily prompting and more assistance in ADLs, along with more monitoring throughout the day.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with lead staff, and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC9099 (FAS) - (06/04)
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