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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400043
Report Date: 06/14/2022
Date Signed: 06/16/2022 10:35:14 AM


Document Has Been Signed on 06/16/2022 10:35 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:BETHEL LUTHERAN HOME, INC.FACILITY NUMBER:
100400043
ADMINISTRATOR:PATTESON, SHIKHAFACILITY TYPE:
740
ADDRESS:2280 DOCKERY AVENUETELEPHONE:
(559) 896-4900
CITY:SELMASTATE: CAZIP CODE:
93662
CAPACITY:33CENSUS: 8DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Shikha PattesonTIME COMPLETED:
02:00 PM
NARRATIVE
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On 6/14/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Administrator Shikha Patteson. LPA toured facility with Administrator. All eight residents were present during the inspection.

Upon entry facility staffs was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed eight single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks. LPA checked residents’ locked medications. LPA observed 30 days PPE supplies. Food supply was checked and appeared to be an adequate supply.

The exterior tour was conducted. Outside free of obstruction. Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information. LPA and Administrator reviewed and observed two out of two staffs that were present during inspection did not have current CPR certification.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 6/20/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610E, Lic 9020, and current liability insurance. LPA received a copy of the Administrator certificate.

A copy of this report and appeal rights was provided to the Administrator via email. Signed report on file.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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 06/16/2022 10:35 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, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: BETHEL LUTHERAN HOME, INC.
FACILITY NUMBER: 100400043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2022
Section Cited

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87202 (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above when LPA and Administrator reviewed and observed staff records. LPA and Administrator observed two out of two staff that were present during inspection did not have current CPR certification on file which poses an immediate health, safety or personal rights risk to persons in care.
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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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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