247200745-1-19-2023-24-AS-BCHN-CNX3R5-20230210172812

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247200745
Report Date: 01/18/2023
Date Signed: 01/19/2023 02:53:23 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
10/25/2022 and conducted by Evaluator Brianna Miranda

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20221025172625

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:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Administrator-Lucinda Fonseca		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident suffered falls while in care.
Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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On 1/18/2023, Licensing Program Analyst (LPA) B. Miranda conducted an unannounced complaint inspection at 11:00 a.m. hours. LPA met with Administrator Sister Lucinda Fonseca. The purpose of this visit is to deliver the finding of the investigation completed by the Department.

LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

On 10/24/2022, the Department received a Suspected Dependent Adult Abuse Report (SOC 341) alleging that a resident (R1) sustained injuries and suffered falls while in care.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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 3

Control Number 24-AS-20221025172625

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW BETHANY	FACILITY NUMBER: 247200745
	VISIT DATE: 01/18/2023

NARRATIVE

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Regarding the resident sustained injuries while in care, R1 fell over nine times between 07/24/2022 and 10/06/2022. On 10/03/2022, facility staff reported that R1 fell and sustained a laceration below R1’s eyebrow and a black eye. Facility staff placed steri-strips on R1’s laceration, but R1 was not sent to hospital and R1’s family was not notified. On 10/06/2022, R1 fell three times before R1 was sent to the hospital. According to a review of medical records, R1 sustained a closed C2 fracture and a right vertebral artery dissection. Facility staff reported that R1 required a higher level of care and should have been moved sooner. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated at this time.

Regarding the resident suffered multiple falls while in care, facility staff were aware that R1 was falling, was weak and hallucinating. According to a review of incident reports and progress notes, R1 had over nine documented falls between 07/24/2022 to 10/06/2022 and not all falls were documented. Facility staff said that they could not provide one on one supervision and R1 kept forgetting to ask for assistance. Facility administrator said that the facility administrator was not notified on 10/03/2022 when R1 fell and sustained a laceration below R1’s eyebrow and the facility administrator was not notified when R1 fell on 10/06/2022 until after R1 had fallen three times. A fall prevention plan was never implemented. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated at this time.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on LIC 9099-D. Failure to correct the deficiency may result in civil penalties. At the time of the complaint inspection on 1/18/2023, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49.

An exit interview was conducted, and a copy of this report dated 1/18/2023 along with Administrator. Appeal Rights (LIC 9058) was provided to Administrator Lucinda Fonseca whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20221025172625

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW BETHANY	FACILITY NUMBER: 247200745
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/19/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 INCIDENTAL MEDICAL AND DENTAL CARE SERVICES 87465 (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.	1 2 3 4 5 6 7	Administrator stated that staff training on meeting each resident’s medical needs will be conducted on 1/20/23 & 1/23/23, completed by 1/27/2023. Administrator agrees to develop a written plan of correction (POC) describing in writing how facility shall ensure compliance with CCR 87465 and how similar incident related to violation will be prevented in the future for health and safety of residents. POC shall be received in licensing office by fax and/or mail by due date. Failure to meet POC due date may result in a civil penalty of $100 or more per day.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and reviews of evidence, licensee failed to arrange for medical care appropriate to the conditions and needs of resident. R1 did not receive proper care resulting in falling and sustaining a closed C2 fracture and a right vertebral artery dissection which poses an immediate health; safety or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 01/19/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 OBSERVATION OF THE RESIDENT 87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	Administrator stated that staff training on providing observation of each resident will be conducted on 1/20/23 & 1/23/23, completed by 1/27/23. Administrator agrees to develop a written plan of correction (POC) describing in writing how facility shall ensure compliance with CCR 87466 and how similar incident related to violation will be prevented in the future for health and safety of residents. POC shall be received in licensing office by fax and/or mail by due date. Failure to meet POC due date may result in a civil penalty of $100 or more per day.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and reviews of evidence, licensee failed to ensure that such changes are documented and brought to the attention of the resident’s (R1) physician. Therefore, R1 did not receive needed medical care and treatment which poses an immediate health; safety or personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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