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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200973
Report Date: 08/03/2023
Date Signed: 08/03/2023 06:48:41 PM


Document Has Been Signed on 08/03/2023 06:48 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: 37DATE:
08/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
07:00 PM
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On 8/3/2023 at 6:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 7/24/2023. LPA met with Manager, Rachell Paniagua.

LPA received incident report on 7/24/2023 for resident (R1). Incident report revealed that R1 was caught climbing out the bedroom window and caregivers tried to stop R1. However, R1 was aggressive and layed down on the roof. Caregiver held R1's feet until police and fire department arrived.

LPA interviewed staff. LPA was informed that R1 climbed out of the window on the third floor and was on the roof. R1 laid down with a pillow on the ledge of the roof right outside the bedroom window. Staff called 911 and police/fire department arrived less than 5 minutes. LPA observed window had alarms and would signal when windows are open. Windows have window screen.

No deficiencies are being cited on this date.

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: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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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