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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200973
Report Date: 03/07/2023
Date Signed: 03/07/2023 10:05:37 AM


Document Has Been Signed on 03/07/2023 10:05 AM - 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: 33DATE:
03/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
10:20 AM
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On 3/7/2023 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a POC (proof of correction) inspection. LPA met with Manager, Rachell Paniagua and informed her the reason for the visit.


The following deficiency was cleared by visit:
- 87468.2(a)(4); LPA received an email from facility on 2/27/2023 with written plan to address AWOL. LPA obtained a copy during inspection.

LPA cleared deficiency cited on 2/24/2023 and provided a copy of the POC letter to manager.


Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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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