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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247200745
Report Date: 07/06/2022
Date Signed: 07/06/2022 01:08:24 PM

Substantiated


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
06/27/2022 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20220627110214
FACILITY NAME:NEW BETHANYFACILITY NUMBER:
247200745
ADMINISTRATOR:FONSECA, JULIAFACILITY TYPE:
740
ADDRESS:1441 BERKELEY DRIVETELEPHONE:
(209) 827-8933
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY:76CENSUS: 43DATE:
07/06/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee Designee Lucinda Fonseca TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not distribute medication to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced to conduct an initial 10-day complaint inspection. LPA discussed the purpose of the visit and the elements of the allegations with the Licensee Designee Lucinda Fonseca.

LPA interviewed staff and residents. LPA reviewed records and toured the facility. Based on interviews conducted with the staff, resident’s, and the MARs review; medication was not dispensed to residents.

The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted and appeal rights
were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
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 2
Control Number 24-AS-20220627110214
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: 07/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2022
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidence by:
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The Licensee agrees to place checks to ensure if medication is missed by Med-Techs a lead person will review the medications and ensure they are dispensed in a timely manner to all residents. Licensee is also interviewing for additional staff to have more coverage on medication dispensing.
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Based on records reviewed and interviews,
staff failed to distribute medication to resident in care, which poses an immediate Health and Safety risk to the residents.
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CCR
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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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2