019200973-12-6-2024-15-AS-HHUL-DBTSKU-20241210125718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200973
Report Date: 12/06/2024
Date Signed: 12/06/2024 05:13:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/03/2023 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20231003131737

FACILITY NAME:	BETHANY HOME SENIOR LIVING, LLC		FACILITY NUMBER:	019200973
ADMINISTRATOR:	NAGY, ARPAD		FACILITY TYPE:	740
ADDRESS:	3322 EAST AVE.		TELEPHONE:	(925) 443-6822
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY:	58	CENSUS: 30	DATE:	12/06/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rachell Paniagua, Manager Chearamy Evangelista, Caregiver		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff failed to provide proper care and supervision to resident resulting in multiple pressure wounds
Staff failed to provide mobility equipment required to move bedridden resident in care

INVESTIGATION FINDINGS:

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On 12/6/2024 at 1:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Manager, Rachell Paniagua and explained to her the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff, residents, witnesses, and complainant. Resident’s physician's report, care plan, preplacement appraisal, emergency information, care notes, incident reports, medical records, home health records, and hospice records were obtained and reviewed.

Staff failed to provide proper care and supervision to resident resulting in multiple pressure wounds:
Home Health medical records revealed that R1 was receiving home health care from 3/10/2022 to 9/1/2022 and was documented by home health nurse as having pressure injuries on R1’s left heel, right heel, and coccyx. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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-20231003131737

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/06/2024

NARRATIVE

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Interview with W1 indicated that R1’s pressure injuries developed prior to admission to the facility. W1 believed that R1’s prior placement was responsible for R1’s pressure injuries. Incident report dated 3/23/2022 revealed that the facility reported R1 had two pressure injuries during admission. Interview with staff and residents indicates consistent statements of staff being attentive to the resident’s care needs. Staff knew to assist R1 with rotating and check on R1 frequently. R1 stated that he was receiving hospice care for coccyx pressure injury.

Staff failed to provide mobility equipment required to move bedridden resident in care
R1’s physician’s report dated 3/2/2022 indicated that R1 is non-ambulatory. R1’s functional capability assessment dated 3/7/2022 revealed that R1 requires assistance with transferring, but able to reposition from side to side. R1’s medical and hospice records did not indicate that R1 required mobility equipment for transfers. Interview with witness revealed that facility staff was assisting R1 in repositioning.

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

Exit interview conducted with Chearamy Evangelista. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

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