247200745-6-26-2020-24-AS-AXIG-BR2RJH-20200629130357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247200745
Report Date: 05/05/2020
Date Signed: 06/26/2020 01:42:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2020 and conducted by Evaluator David Ayers

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20200206134656

FACILITY NAME:	NEW BETHANY		FACILITY NUMBER:	247200745
ADMINISTRATOR:	FONSECA, JULIA		FACILITY TYPE:	740
ADDRESS:	1441 BERKELEY DRIVE		TELEPHONE:	(209) 827-8933
CITY:	LOS BANOS	STATE: CA	ZIP CODE:	93635
CAPACITY:	76	CENSUS:	DATE:	05/05/2020
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Julia Fonseca- Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff hit resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this date, Licensing Program Analyst (LPA) David Ayers contacted the facility to deliver findings for a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call and the elements of the findings with administrator Julia Fonseca.

During the course of the investigation, the Department conducted interviews, inspected the facility, and reviewed records. On 2/2/2020, staff S1 responded to a call from resident R1 in R1's room. S1 stated that R1 was on the floor next to his bed and had a visible injury to his mouth. S1 called for help from another staff S2 to lift R1 back to his bed. R1 was unable to recall the incident. S1 stated that she did not hit R1. The above allegation is unsubstantiated. Exit interview conducted with administrator Julia Fonseca via telephone and a copy of this report provided to the licensee via email. A read receipt confirms the licensee receives these documents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 1