100400043-1-31-2023-24-AS-SMOA-CNULPW-20230208075634

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 100400043
Report Date: 01/28/2023
Date Signed: 01/31/2023 04:32:23 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
12/14/2022 and conducted by Evaluator Mary Garza

COMPLAINT CONTROL NUMBER: 24-AS-20221214161734

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: 12	DATE:	01/28/2023
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Director of Nursing, Sam Parvinder		TIME COMPLETED:	11:06 AM

ALLEGATION(S):

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Resident not able to have visitors.

INVESTIGATION FINDINGS:

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On 1/28/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility for an unannounced complaint visit to deliver findings. 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.

During investigation LPA requested and reviewed documentation (resident roster, staff roster and contact information, visitor log for one month, house rules and a copy of daily schedule for residents). LPA observed a sign on the door with visiting hours (10-4) and “must call to schedule appointment”. Interviews conducted with staff support the allegation. The allegation listed above has met the preponderance of evidence standard per Title 22 and is found to be SUBSTANTIATED.

Deficiencies cited on 9099D. Exit interview completed with DON, Sam. A copy of this report and appeal rights given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20221214161734

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CCR 87468.1(a)(11)	1 2 3 4 5 6 7	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 (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.	1 2 3 4 5 6 7	Visiting hours to be extended. Entrance for Assisted Living side will have a separate entry. In Service training to be completed with all staff. Training material and sign in sheet to be provided to CCL by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: LPA observation and interviews completed. LPA observed sign on front door which stated visits were to be scheduled and between the hours of 10 am and 4 pm. This poses a potential personal rights, health and/or safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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