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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601335
Report Date: 09/05/2024
Date Signed: 09/05/2024 10:41:48 AM


Document Has Been Signed on 09/05/2024 10:41 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BETHANY HOME/HARVARD MANORFACILITY NUMBER:
015601335
ADMINISTRATOR:NAGY, LEVENTEFACILITY TYPE:
740
ADDRESS:3957 HARVARD WAYTELEPHONE:
(925) 443-6822
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 0DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Elizabeth Nagy, AdministratorTIME COMPLETED:
10:55 AM
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On 9/5/2024 at 8:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with administrator, Elizabeth Nagy and explained the purpose of the visit. LPA observed facility currently does not have residents present.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 6/23/2024. Facility had some perishable and non-perishable food supplies available. Administrator will obtain additional food supplies prior to admitting residents to the facility. Hot water temperature was measured at 105.5 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. First Aid kit is complete.
LPA reviewed Administrator's file and interviewed staff during inspection

Technical assistance was given during inspection.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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