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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400043
Report Date: 01/28/2023
Date Signed: 01/31/2023 04:33:09 PM


Document Has Been Signed on 01/31/2023 04:33 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
SIERRA CASCADE AC/SC, 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: 12DATE:
01/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Director of Nurses, Sam Parvinder TIME COMPLETED:
12:09 PM
NARRATIVE
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On 1/28/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility for an unannounced case management visit. LPA met by receptionist. Administrator was contacted but unavailable. LPA was given permission to meet with Director of Nursing (DON), Sam Parvinder. LPA was COVID pre-screened at entry. LPA completed a Health and Safety check on residents in care. Residents observed in hallway and in rooms at time of visit.

Upon arrival to facility LPA observed front entrance door to be locked. During previous visit on 12/16/2022. The following issues were observed: The front entrance door was locked not allowing residents, visitors and staff to come in and out freely. The janitor closet was unlocked with chemicals accessible to residents in care. These pose a potential personal rights, health and/or safety rights risk to residents in care.

Deficiencies cited per Title 22 on 809D. Exit interview completed with DON, Sam Parvinder. A copy of this report and appeal rights given.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/31/2023 04:33 PM - 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/08/2023
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night...
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Door will remain unlocked. Entrance for Assisted Living side will have a separate entry from SNF. In Service training to be completed with all staff. Training material and sign in sheet to be provided to CCL by POC date.
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This requirement was not met by LPA observation of front door being locked on 12/16/2022 and 1/28/23 during visits to facility not allowing residents to leave and return freely. This poses a personal rights, health and/or safety risk to residents in care.
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Type B
02/08/2023
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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In service training to be completed with all housekeeping staff. Training material and sign in sheet to be provided to CCL by POC date.
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This requirement was not met as evidence by LPA observation of janitor closet being unlocked with chemicals accessible to residents in care. This poses a potential personal rights, health and/or safety risk to resident 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: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2