011400061-2-28-2023-15-AS-BFOG-CRVPJY-20230516112215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011400061
Report Date: 02/28/2023
Date Signed: 02/28/2023 06:25:11 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2023 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20230215113247

FACILITY NAME:	BETHESDA HOME		FACILITY NUMBER:	011400061
ADMINISTRATOR:	DAVID R. MARTINEZ		FACILITY TYPE:	740
ADDRESS:	22427 MONTGOMERY		TELEPHONE:	(510) 538-8300
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	28	CENSUS: 16	DATE:	02/28/2023
		UNANNOUNCED	TIME BEGAN:	06:15 PM
MET WITH:	Infection Preventionist LVN Cynthia Angeles		TIME COMPLETED:	06:35 PM

ALLEGATION(S):

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Facility did not provide sufficient supervision resulting to resident (R1) sustaining right femur fracture.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Infection Preventionist LVN Cynthia Angeles,.and informed the purpose of visit.

During the course of investigation, the Department obtained copies of resident roster for the Assisted Living (AL), Independent Living and Skilled Nursing (SNF) units of Bethesda, and conducted interviews. Resident roster showed R1 is not listed on AL unit.

On 2/23/23, David Martinez, administrator, was interviewed who stated R1 was admitted to SNF section of the facility, and never was admitted to AL unit. On 2/24/23, R1’s daughter (FM) was interviewed, and confirmed R1 was never admitted to AL. FM stated R1 was directly admitted to SNF section of Bethesda.

.....continued on 9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023

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 15-AS-20230215113247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BETHESDA HOME	FACILITY NUMBER: 011400061
	VISIT DATE: 02/28/2023

NARRATIVE

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Based on records review and interviews, the allegation of facility did not provide sufficient supervision resulting to resident (R1) sustaining right femur fracture is closed as unfounded due to R1 is a resident of facility’s SNF unit which is not under the jurisdiction of the Department. A finding that a complaint is unfounded means that allegation is false and could not have happened and/or are without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023

LIC9099 (FAS) - (06/04)

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