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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200745
Report Date: 04/14/2022
Date Signed: 04/15/2022 11:13:28 AM


Document Has Been Signed on 04/15/2022 11:13 AM - 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:BETHEL CARE HOME ON JUANITAFACILITY NUMBER:
079200745
ADMINISTRATOR:CHAUDHRY, TAYYABAFACILITY TYPE:
740
ADDRESS:1391 JUANITA DRIVETELEPHONE:
(925) 433-6000
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Tayyaba ChoudhryTIME COMPLETED:
05:30 PM
NARRATIVE
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On 04/14/2022 at 2:15 PM, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced infection control and required one year inspection. Upon arrival, LPA was greeted by staff S1. LPA explained the purpose of the visit to S1 and toured the facility inside and outside. Licensee Tayyaba Chaudhry arrived at 2:45 PM and toured the facility with the LPA.

LPA observed staff wearing face masks during visit. LPA discussed the posted emergency disaster plan (LIC 610E) and mitigation plan (LIC 808) with Ms. Chaudhry. LPA was screened for Covid-19 and the staff use of the visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe for screening. Routine symptom screening (+/-) temperature and symptom check are done at entry for all staff, residents and visitors. LPA observed COVID-19 signs posted in common areas to promote hand washing, cough/sneeze etiquette, and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents.

During the visit, pathways were observed to be free of obstruction and fire hazards. Last Fire drill was conducted on 01/17/2022. Facility room temperature was maintained at a comfortable 73.8 degrees Fahrenheit and the hot water temperature was 105 degrees Fahrenheit.

The problem identified at the facility, however, were the numerous safety devices in need of repair that did create a Type A citation, such as the child proof lock under kitchen sink where cleaning solutions stored that could be opened, the door on an exterior storage building with a malfunctioning door handle lock, and dead batteries on the auditory signal device for the sliding glass door to the back yard.

Due to a computer problem, the exit interview was conducted with Licensee Chaudhry on 04/15/2022 when a copy of this report was provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
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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Document Has Been Signed on 04/15/2022 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BETHEL CARE HOME ON JUANITA
FACILITY NUMBER: 079200745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Send picture proof of completed repairs: (1) fully operable under kitchen sink locks, (2) door on outside building has a fully functioning lock on exterior door, (3) outside lectrical outlet and fence board repaired, (4) written procedure for replacement of batteries and repair of all auditory door open devices, garbage can lids, and all other devices using batteries or replace them with mechanical, non-electronic devices.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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