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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200320
Report Date: 04/07/2025
Date Signed: 04/07/2025 03:35:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
04/01/2025 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250401104140
FACILITY NAME:BETHEL CARE HOME ON COTTAGEFACILITY NUMBER:
079200320
ADMINISTRATOR:CARLA BLAJFACILITY TYPE:
740
ADDRESS:36 COTTAGE LANETELEPHONE:
(925) 280-6000
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
04/07/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Carla BlajTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not receive resident after being discharged from the hospital in a timely manner.
INVESTIGATION FINDINGS:
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On 4/7/2025, at 2:00 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to investigate the allegation above. Upon arrival, the LPA informed Administrator (ADM) Carla Blaj of the purpose of the visit.

The complaint alleges staff did not receive resident after being discharged from the hospital in a timely manner.
The LPA interviewed Witness W1 by telephone. The LPA interviewed the ADM concerning the refusal to accept Resident R1 immediately after being discharged from the hospital. The ADM explained that the delay was not because of staffing or any other facility-related issues. Instead, it was based on R1's care needs, which would have been negatively impacted by the transportation from the hospital to the facility at midnight. The data collected from the interviews shows that the staff were acting in best interest of R1, which does not confirm the allegation.

Continued on LIC 9099-C . . .
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20250401104140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BETHEL CARE HOME ON COTTAGE
FACILITY NUMBER: 079200320
VISIT DATE: 04/07/2025
NARRATIVE
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. . . Continued from LIC 9099

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2