100400043-2-26-2021-24-AS-AXIG-BZUPDK-20210407111339

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 100400043
Report Date: 02/12/2021
Date Signed: 02/26/2021 08:32:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2021 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20210211162343

FACILITY NAME:	BETHEL LUTHERAN HOME, INC.		FACILITY NUMBER:	100400043
ADMINISTRATOR:	PATTESON, SHIKHA		FACILITY TYPE:	740
ADDRESS:	2280 DOCKERY AVENUE		TELEPHONE:	(559) 896-4900
CITY:	SELMA	STATE: CA	ZIP CODE:	93662
CAPACITY:	33	CENSUS: 5	DATE:	02/12/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Shika Patteson-Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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9

Facility did not report suspected abuse

INVESTIGATION FINDINGS:

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13

On this date, Licensing Program Analyst (LPA) David Ayers contacted the facility to conduct an initial 10-day complaint inspection via telephone due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call with Administrator Shika Patteson.

LPA requested records and interviewed administrator . The resident(R1) who is the subject of the complaint resides in the Skilled Nursing Facility which is adjoins the Residential Care Facility for the Elderly(RCFE). R1 has not been a resident of the RCFE. The allegation is unfounded. Exit interview conducted with Administrator via telephone and a copy of this report provided to the licensee via email. A read receipt confirms the Administrator receives these documents.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

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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