247200745-2-24-2021-24-AS-AXIG-BYKND3-20210225092138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247200745
Report Date: 02/11/2021
Date Signed: 02/24/2021 11:56:52 AM

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
10/19/2020 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20201019115918

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: 46	DATE:	02/11/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Julia Fonseca-Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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9

Facility lacks sufficient staffing to meet residents' needs.

INVESTIGATION FINDINGS:

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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 Director Lucinda Fonseca.

During the course of the investigation, LPA conducted a virtual inspection of the facility, conducted interviews, and reviewed records. The Responsible Party for Resident 1 (R1) stated that R1 had fallen multiple times in the facility, and on the morning of 10/19/2020 waited a "very long time" for assistance to arrive. Staff 1 (S1) stated that the facility is understaffed, and that staff cannot meet the needs of some residents. At the time of the allegation, the facility had 52 residents. Eight of the residents had dementia and were residing in the designated memory-care wing. One caregiver is scheduled to work the overnight shift from 10pm-6am, with 1 additional staff member on-call.

The allegation is substantiated. See LIC 9099D for citation issued in accordance with California Code of Regulations, Title 22. Exit interview conducted with administrator via telephone and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) provided to the licensee via email. A read receipt confirms the licensee receives these documents.

Substantiated

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: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

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 24-AS-20201019115918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: NEW BETHANY	FACILITY NUMBER: 247200745
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/25/2021 Section Cited CCR 87705(c)(4)(A)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.(A)In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to colaborate with LPA to develop and submit a plan to address strategies to meet the needs of the residents and ensure sufficient staffing.
	8 9 10 11 12 13 14	Based on interview and records review, on 10/19/2020 the facility lacked sufficient staff to respond to R1's call for assistance in a timely manner. Due to the layout of the facility and the number of residents at the time(52), facility staff were unable to meet residents' needs.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC9099 (FAS) - (06/04)

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