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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200973
Report Date: 09/18/2024
Date Signed: 09/18/2024 01:38:57 PM


Document Has Been Signed on 09/18/2024 01:38 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: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: 32DATE:
09/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Rachell Paniagua/ManagerTIME COMPLETED:
01:45 PM
NARRATIVE
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While conducting an investigation of a complaint (Control # 15-AS-20221107163346), the Department learned that the facility did not do reappraisal and update Care Plan when R1's conditions changed. Medical records revealed R1 sustained fracture as a result of fall on October 10, 2022, and S1 stated R1's Care Plan was not updated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Rachell Paniagua.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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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Document Has Been Signed on 09/18/2024 01:38 PM - It Cannot Be Edited

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 SENIOR LIVING, LLC
FACILITY NUMBER: 019200973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2024
Section Cited
CCR
87463(a)

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87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental,
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The resident is no longer at the facility.

Administrator to read the Regulations and ensure reappraisal is completed accordingly and as needed. Self-certification to be submitted by 10/02/24.
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....and social condition.
-This requirement is not met as evidenced by:
-Based on records review and interview, the licensee did not comply with the section above for not doing reappraisal when R1's condtion changed which posed a potential health, safety and/or personal rights risks.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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