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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400043
Report Date: 06/04/2025
Date Signed: 06/05/2025 11:39:16 AM

Document Has Been Signed on 06/05/2025 11:39 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BETHEL LUTHERAN HOME, INC.FACILITY NUMBER:
100400043
ADMINISTRATOR/
DIRECTOR:		PATTESON, SHIKHAFACILITY TYPE:
740
ADDRESS:2280 DOCKERY AVENUETELEPHONE:
(559) 896-4900
CITY:SELMASTATE: CAZIP CODE:
93662
CAPACITY: 33CENSUS: 14DATE:
06/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Kristine Williams, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 06/04/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit and met Administrator Kristine Williams and Licensed Vocational Nurse Kamal Singh. LPA toured facility with Administrator.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Fire extinguisher was observed throughout the facility with a service date of: 04/26/25. Last fire drill completed on 04/15/25. Fire sprinkler systems observed throughout the facility. Medications were observed locked in medication cart in medication room. MARs and medications were reviewed.

A sample of residents’ bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured and observed operational during inspection. Hot water tested maintained at 109.2 degrees F in room 13, 105.2 degrees F in room 15, 107.2 degrees F in room 17, and 106.8 degrees F in room 23. Non-skid mat and grabbed bars were observed.

An adequate supply of perishable and non-perishable food was observed. Adequate outdoor seatings available for residents and outside observed free of debris. Refrigerator temperature is maintained at 36 degrees F and freezer at -4 degrees F. Food delivery once a week and kitchen are shared with skill nursing facility. A sample of resident and staff files were reviewed.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
VISIT DATE: 06/04/2025
NARRATIVE
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A deficiency and an immediate Civil Penalty was assessed. See Lic 421BG and Lic 421IM is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 06/10/25. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Theft and Loss Policies and Procedures, Administrator certificate, and current liability insurance. LPA copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 11:39 AM - It Cannot Be Edited


Created By: Mai Yang On 06/04/2025 at 03:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355(e)(2)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Administrator is not associated to facility which poses an immediate risk to the health and safety of the residents
POC Due Date: 06/05/2025
Plan of Correction
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LIC 9182 Fingerprint transfer request is to be submitted to Fresno CCL office by POC due date 06/05/25.
Type A
Section Cited
CCR
87465(d)(3)
87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observations and records reviewed, R5’s medication Premarin Vag w/ App 0.625mg was administered and record in the resident’s MAR, which poses/ posed a potential health and safety risk for the person in care.
POC Due Date: 06/06/2025
Plan of Correction
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Administrator agrees to provide a statement detailing steps the facility will take to ensure to met the regulation to the Fresno CCL by POC due date 06/06/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 11:39 AM - It Cannot Be Edited


Created By: Mai Yang On 06/04/2025 at 03:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
87211(a)(1) Each licensee shall furnish to the licensing agency. (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.

This was not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and interviews conducted, R1 went to the hospital on 01/12/25, R2 went to the hospital on 02/25/25 and on 03/03/25, and R3 went to the hospital on 01/04/25. No records of incident reported to the department of residents’ hospitalization, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 06/06/2025
Plan of Correction
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Administrator agrees to provide a statement detailing steps the facility will take to ensure to met the reporting regulation to the Fresno CCL by POC due date 06/06/25.
Type B
Section Cited
CCR
873039(a)
873039(a) 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, bathroom sink was linking water in Room 13, which poses/ posed a potential health and safety risk to the resident in care.
POC Due Date: 06/13/2025
Plan of Correction
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Maintenance staff repaired bathroom sink during inspection. POC cleared during visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 11:39 AM - It Cannot Be Edited


Created By: Mai Yang On 06/04/2025 at 04:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview conducted, observation, and records reviewed, R1 and R4 uses half rail bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 06/09/2025
Plan of Correction
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Administrator shall obtain doctor orders for R1 and R4 indicating the need for half bed rail and if physician do not indicate the need for half bed rail, hail rail must be removed by POC due date 06/09/25.
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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
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