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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601335
Report Date: 09/03/2021
Date Signed: 09/03/2021 10:32:25 AM

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:BETHANY HOME/HARVARD MANORFACILITY NUMBER:
015601335
ADMINISTRATOR:NAGY, LEVENTEFACILITY TYPE:
740
ADDRESS:3957 HARVARD WAYTELEPHONE:
(925) 443-6822
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 2DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Elizabeth Nagy, AdministratorTIME COMPLETED:
10:45 AM
NARRATIVE
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On 9/3/2021 at 8:35AM, Licensing Program Analysts (LPAs) G. Luk and C. Lin arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Elizabeth Nagy and explained the purpose of the visit.

Upon entry, LPA's temperatures were checked by staff and asked to fill out COVID-19 questionnaire. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitors log and facility has a copy of Mitigation Plan on file. LPAs observed PPEs, food, and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 9:30AM, LPAs observed facility was not documenting resident's changes in condition.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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: BETHANY HOME/HARVARD MANOR
FACILITY NUMBER: 015601335
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not documenting resident's changes in condition which poses a potential health and safety risk to persons in care.
POC Due Date: 09/10/2021
Plan of Correction
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Administrator has agreed to conduct training for staff on documenting resident's changes in condition and submit staff sign-in sheet to CCLD by POC date.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021
LIC809 (FAS) - (06/04)
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