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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200973
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:41:05 PM

Substantiated


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
12/22/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211222164139
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:
02/24/2023
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff do not provide adequate care to wandering residents
Facility failed to report to CCL unusual incidents
INVESTIGATION FINDINGS:
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On 2/24/2023 at 11:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegations above. LPA met with Manager, Rachell Paniagua.

During the course of investigation, LPA interviewed 3 staff. LPA obtained and reviewed documents including physician's report, care plan, incident report, and medication training documents for 3 staff.

Staff do not provide adequate care to wandering residents
Interview with staff reviewed that R1 AWOL twice and R2 AWOL once. S2 stated that key alarms were not installed until after R1's first AWOL. Incident report dated 12/21/2021 indicated that R1 was found by local police and brought back to the facility about an hour after AWOL. R1's physician's report dated 11/14/2021 indicated that R1 has wandering behaviors and cannot leave the facility unassisted.
(Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20211222164139
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: 02/24/2023
NARRATIVE
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Facility failed to report to CCL unusual incidents
Interview with staff revealed that another AWOL was not reported to CCLD. After reviewing incident reports submitted by the facility, LPA observed that only one AWOL was reported to CCLD in 2021.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

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: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20211222164139
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/27/2023
Section Cited
CCR
87468.2(a)(4)
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***This is an amended report from visit on 2/24/2023***

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs...by staff that are sufficient in numbers... This requirement is not met as evidence by:
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***This is an amended report from visit on 2/24/2023***

Facility has agreed to create a written plan to address future wandering behaviors and submit the written plan to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by having residents leave the facility unassisted which poses an immediate health and safety risk to the persons in care.
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Type B
03/17/2023
Section Cited
CCR
87211(a)(1)
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***This is an amended report from visit on 2/24/2023***

Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified... This requirement is not met as evidence by:
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***This is an amended report from visit on 2/24/2023***

Facility has agreed to re-train staff on reporting requirements and submit staff sign-in sheet & training materials to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not submitting incident report to CCLD which poses a potential health and safety risk to the persons in care.
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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: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
12/22/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211222164139

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:
02/24/2023
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Medication technicians do not have the required training
INVESTIGATION FINDINGS:
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On 2/24/2023 at 11:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPA met with Manager, Rachell Paniagua.

During the course of investigation, LPA interviewed 3 staff. LPA obtained and reviewed documents including physician's report, care plan, incident report, and medication training documents for 3 staff. LPA reviewed medication training documents for 3 staff and observed they all had their annual 8 hours of medication training in 2021.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4