079200309-9-29-2022-15-AS-HHUL-CKZW4W-20221109155813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200309
Report Date: 09/29/2022
Date Signed: 09/29/2022 01:17:23 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
08/09/2022 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20220809095150

FACILITY NAME:	BETHANY HOME		FACILITY NUMBER:	079200309
ADMINISTRATOR:	NAGY, ARPAD		FACILITY TYPE:	740
ADDRESS:	2201 ROCKNE DRIVE		TELEPHONE:	(925) 640-6403
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	6	CENSUS: 6	DATE:	09/29/2022
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Telesha Clarke, Administrator		TIME COMPLETED:	01:27 PM

ALLEGATION(S):

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9

Resident wandered from the facility

INVESTIGATION FINDINGS:

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On 09/29/2022 at 12:40 PM, Licensing Program Analysts (LPA), J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPA met with Telesha Clarke, Administrator and explained the reason for the visit.

During the course of investigation, LPA obtained information, collected documents and interviewed staff and witnesses. Based on interview with staff (S1), it was revealed that R1 had AWOL’ed from the facility on more than one occasion. S1 also stated that there were staff at the facility during that time but were asleep.

On the allegation Facility does not have adequate night supervision, Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited.

Exit interview conducted. A copy appeal rights, and this report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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-20220809095150

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	FACILITY NUMBER: 079200309
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/06/2022 Section Cited CCR 87705(c)(4)(A)	1 2 3 4 5 6 7	Licensees who accept and retain residents with dementia...Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty...	1 2 3 4 5 6 7	Licensee shall complete an LIC500, verifying facility is adequately staffed at all times. Licensee shall submit to licensing, a copy of current LIC500 by POC date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: The facility having a resident AWOL, and the staff were not awake when the police arrived to assist in returning her to the facility.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC9099 (FAS) - (06/04)

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