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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200309
Report Date: 06/27/2023
Date Signed: 06/27/2023 12:12:26 PM


Document Has Been Signed on 06/27/2023 12:12 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 HOMEFACILITY NUMBER:
079200309
ADMINISTRATOR:NAGY, ARPADFACILITY TYPE:
740
ADDRESS:2201 ROCKNE DRIVETELEPHONE:
(925) 640-6403
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 5DATE:
06/27/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH: Telesha Clarke, AdministratorTIME COMPLETED:
12:30 PM
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On 06/27/2023 at 12:00 PM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted an unannounced Health & Safety inspection. LPA met with Administrator, Telesha Clarke.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, medication room, and outdoor area. 7-days of non-perishables and 2-days of perishable food supplies were present. Resident's medications were kept locked in the medication room. Smoke and carbon monoxide detectors are combined and observed throughout the facility and the bedrooms. First-aid kit was complete. Fire extinguisher was observed to be full and last inspected 04/16/2023. No accessible bodies of water were observed. Indoor and outdoor passageways were free of obstruction.

No deficiencies are cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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