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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200973
Report Date: 04/12/2021
Date Signed: 04/12/2021 03:19:05 PM

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 SENIOR LIVING, LLCFACILITY NUMBER:
019200973
ADMINISTRATOR:NAGY, ARPADFACILITY TYPE:
740
ADDRESS:3322 EAST AVE.TELEPHONE:
(925) 443-6822
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:58CENSUS: 0DATE:
04/12/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Arpad Nagy, LicenseeTIME COMPLETED:
01:00 PM
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On 4/12/2021 at 10:00AM, Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit Pre-Licensing inspection via FaceTime due to shelter in place directed by the Governor. LPA spoke with Licensee, Arpad Nagy. The facility's fire clearance was approved for 58 non-ambulatory residents.

During the Tele-visit, LPA toured facility with Licensee including but not limited to resident's bedrooms, bathrooms, dining room, common area, kitchen, and outdoor area. One of the resident's bedroom was fully furnished with bed, dresser, night stand, and chair. Licensee agreed to purchase additional furniture for resident's rooms prior to residents moving into the facility. Resident's bathrooms were equipped with grab bars and non-skid mats/material. LPA observed non-perishable food supplies. Facility has new refrigerators and freezer at the facility that were not plugged in at the time of inspection. LPA reminded licensee that the refrigerator temperature should not exceed 40 degrees F and freezer temperature should not exceed 0 degrees F. Facility has lockable medication carts located in the medication room. Smoke detectors are interconnected with sprinkler system. Licensee purchased carbon monoxide detectors for each floor during inspection and LPA observed all floors have carbon monoxide detectors. First aid kit is complete. LPA reminded licensee that hot water temperature should be maintained between 105 degrees F and 120 degrees F. Facility provided purchase receipt for the evacuation chairs on each stairwell to LPA. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was observed to be full and last serviced on 2/1/2021.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

LPA conducted Component III with Licensee during Tele-visit. LPA presented Component III Power Point and discussed the regulations embodied in the presentation. Exit interview conducted and a copy of this report will be emailed.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
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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