<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201265
Report Date: 07/22/2024
Date Signed: 07/22/2024 05:36:03 PM


Document Has Been Signed on 07/22/2024 05:36 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 HOMES SENIOR LIVING IIFACILITY NUMBER:
019201265
ADMINISTRATOR:PANIAGUA, RACHELLFACILITY TYPE:
740
ADDRESS:3356 EAST AVETELEPHONE:
(925) 640-6403
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:20CENSUS: 6DATE:
07/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rachell Paniagua, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/22/2024 at 1:00PM, Licensing Program Analyst (LPA) G. Luk conducted a Pre-licensing Inspection. LPA met with Administrator, Rachell Paniagua.


LPA toured facility including but not limited to resident's bedrooms, bathrooms, common areas, dining area, kitchen, and outdoor area. LPA observed lighting in all rooms. LPA observed facility has one week of non-perishable and two days of perishable food supplies available. Smoke detectors are interconnected with sprinkler system. Carbon monoxide detectors were observed. First aid kit was complete. Emergency disaster plan was complete. Fire extinguishers were observed to be full and last serviced on 5/17/2024. Hot water was originally measured at 124 degrees F and administrator lowered hot water. LPA re-measured hot water at 109.7 degrees F.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. LPA observed back yard area has lots of items to be disposed including hoyer lift, bed frames, water heater, wheelchairs, and other items.

2. LPA observed back yard area has some benches. However, there was no shaded areas for residents.

Licensee/Applicant will submit proof of corrections to CCLD on/before 8/5/2024.


Exit interview conducted and 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: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1