247200745-2-24-2021-24-AS-AXIG-BYKND4-20210225092138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247200745
Report Date: 02/11/2021
Date Signed: 02/24/2021 11:56:16 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):

1
2
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5
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8
9

Lack of supervision resulting in resident sustaining a fall.

INVESTIGATION FINDINGS:

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5
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9
10
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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 and Director Lucinda Fonseca.

During the course of the investigation, LPA conducted a virtual inspection of the facility, conducted interviews, and reviewed records. According to statements from facility staff and the Responsible Party(RP) of Resident 1(R1), R1 fell in their room on the morning of 10/19/2020. R1 did not attempt to call for assistance until after the fall occurred.

The allegation is Unsubstantaited. Exit interview conducted with administrator via telephone and a copy of this report was 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: 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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