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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400043
Report Date: 06/17/2024
Date Signed: 06/20/2024 03:53:55 PM


Document Has Been Signed on 06/20/2024 03:53 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: 15DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Shikha Patterson and Licensed Vocational Nurse Teresa GonzaleTIME COMPLETED:
04:00 PM
NARRATIVE
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On 06/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met Administrator Shikha Patterson and Licensed Vocational Nurse Teresa Gonzalez. 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 with a service date of: 03/08/24.
All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured and observed operational during inspection. Non-skid mat and grabbed bars were observed. An adequate supply of perishable and non-perishable food was observed. Freezer temperature maintained at 0 degree F and refrigerator temperature maintained at 20 degrees F. Medications were observed locked in medication cart in medication room. MARs and medications were reviewed. Adequate outdoor seatings available for residents. A sample of resident and staff files were reviewed. Refrigerator temperature is maintained at 40 degrees F and freezer at 0 degrees F. Food delivery once a week and kitchen is shared with skill nursing facility.

A deficiency and an immediate Civil Penalty of $500 was assessed. See Lic 421BG is being cited on the
attached Lic 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: 06/24/24.
The following updated forms were requested: Lic 308, Lic 500, Lic 610E, 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.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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 06/20/2024 03:53 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: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)
The following requirements shall apply to medications which are centrally stored

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and LVN observed prescribed medication stored in R1’s bathroom. LPA audit R1’s medication and review MARS and one of R1’s medication was not stored in the facility which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 06/18/2024
Plan of Correction
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Licensee shall ensure that all medications shall be locked and inaccessible to residents in care. Proof of medications
removed and locked, inaccessible to residents shall be submitted to the department by POC due date 06/18/24.
Proof of R1’s medication has been order shall be submitted to the department by POC due date.
Type A
Section Cited
CCR
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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S1 is not associated to facility which poses an immediate risk to the health and safety of the residents. .
POC Due Date: 06/18/2024
Plan of Correction
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S1 had left for the day from her shift. S1 is not permitted back until associated. Licensee to submit LIC 9182 Fingerprint transfer request to Fresno CCL office by POC due date 06/18/24.
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) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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