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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400061
Report Date: 05/01/2024
Date Signed: 05/01/2024 06:22:10 PM


Document Has Been Signed on 05/01/2024 06:22 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BETHESDA HOMEFACILITY NUMBER:
011400061
ADMINISTRATOR:DAVID R. MARTINEZFACILITY TYPE:
740
ADDRESS:22427 MONTGOMERYTELEPHONE:
(510) 538-8300
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:28CENSUS: 14DATE:
05/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Roselyn Chand/Acting Administrator TIME COMPLETED:
06:30 PM
NARRATIVE
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On this day at 2:00 p.m., Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual inspection. LPA met with Roselyn Chand, acting administrator, and informed the reason for visit.

LPA requested for copy of updated LIC9282 Infection Control Plan which LPA received on 4/23/24. Another updated LIC9282 is provided by acting administrator on this day,

LPA inspected the facility inside out with the acting administrator. LPA inspected the main building (West Wing); Azalea, Garden and Peralta Cottages. LPA randomly selected residents rooms in the West Wing and cottages for inspection. LPA also inspected the living room, dining area, kitchen, bathrooms, toilets, shower room and yard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. Facility uses mechanical means of cleaning/rinsing dishes and utensils. Kitchen staff check and keep record of freezers and refrigerators temperatures which were observed within Regulations range.

Facility has smoke detectors that were tested, and observed functional. Hot water temperature in one of the ensuite bathrooms in the West Wing was tested, and measured at 108 degrees Fahrenheit. Fire extinguishers were checked, observed fully charge with tags showed serviced 2/27/24.

LPA interviewed 2 residents. Facility does not handle residents' cash resources.

LPA observed the following:
-at 2:55 p.m., trash can in West Wing resident's bathroom without lid.
-at 3:45 p.m., fire place in the West Wing living room not secured.
-facility does not have a certified administrator. Former administrator last day at the facility was 11/2023.

....continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/01/2024
NARRATIVE
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Page 2

-disaster drill records not readily available for review.
-no carbon monoxide detectors in the West Wing, Azalea, Peralta

Acting administrator to submit updated copies of the following documents by May 15, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan
4. $3M Liability Insurance certificate

Due to time constraint, LPA will come back to continue the inspection.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan, and proof of corrections were discussed with the acting administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/01/2024 06:22 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BETHESDA HOME
FACILITY NUMBER: 011400061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in not having carbon monoxide detectors in the West Wing and Azalea and Peralta Cottages which pose an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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2
3
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Administrator to have carbon monoxide detectors installed, and submit pictures by 5/02/24.
Type A
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.

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 in fire place in the living room not adequately screened which poses an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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Administrator to have the fire place properly screened and locked, and send picture by 5/02/24.
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/01/2024 06:22 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BETHESDA HOME
FACILITY NUMBER: 011400061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

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 in trash can in West Wing resident's bathroom without lid which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Administrator to purchase trash can with foot pedal operated lid, and submit picture by 5/15/24.
Type B
Section Cited
CCR
87755(c)

87755 Inspection Authority of the Licensing Agency
(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying.......

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in not having the disaster drill records not readily availabe for review which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Administrator to submit copies of drill records for the last 3 quarters by 5/15/24.
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/01/2024 06:22 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BETHESDA HOME
FACILITY NUMBER: 011400061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section.......

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in not having a certified administrator which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Acting administrator stated she has completed the required training to renew her administrator certificate.
Acting administrator to submit the following by 5/15/24: proof of completiion and payment for certification; job offer from licensee; signed letter from licensee requesting to expedite the processing of administrator certificate
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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5