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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200973
Report Date: 09/04/2025
Date Signed: 09/04/2025 05:13:30 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
03/04/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250304113131
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: 30DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff do not remain awake during overnight shifts
INVESTIGATION FINDINGS:
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On 9/4/2025 at 10:30AM, 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 and explained the purpose of the visit.

During the course of investigation, LPA interviewed resident, staff, and witnesses. LPA obtained and reviewed documents including physician's report, emergency information, staff schedule, and incident reports. Interview with witnesses revealed that R1 was discharged from hospital at around 1:00AM on 3/4/2025 and transported back to the facility via ambulance. Witnesses stated ambulance rang the facility bell for about an hour without response from facility staff and ambulance took R1 back to hospital around 3:00AM on 3/4/2025.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted with Rachell Paniagua. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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-20250304113131
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: 09/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2025
Section Cited
CCR
87415(a)(2)
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Night Supervision. In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes.
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Facility has agreed to create a written plan to address night staff schedule to ensure awake staff is present during night shift. Facility will submit plan to CCLD by POC date.
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This requirement is not met as evidence by: Based on interviews, licensee did not comply with the section cited above by not having an awake staff at night shift which poses a potential health and safety risk to the persons in care.
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Additionally, facility will submit an updated LIC500 to CCLD by POC date.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
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