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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247200745
Report Date: 09/27/2024
Date Signed: 09/27/2024 01:53:38 PM


Document Has Been Signed on 09/27/2024 01:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



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: 39DATE:
09/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Basuny EldaouchTIME COMPLETED:
02:00 PM
NARRATIVE
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On 9/27/2024 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management regarding an incident report received from the facility listed above. LPA introduced herself and explained the reason for the visit. LPA was allowed entrance into the facility. LPA met with Sister Astrida D. Cruz (SAC) and Basuny Eldaouch (BE- New Administrator)

The Dept. received an incident report stating caregiver found R1 to have a swollen ankle on 9/15/2024 and it was reported. R1 previously had a fall the week before. Basuny Eldaouch stated he spoke with the doctor who stated the fracture may have occurred due to R1 hitting their ankle while walking with the walker. No previous reports were submitted regarding the fall prior to 9/15/24.

LPA interviewed R1. LPA was shown incident report for a fall on 8/7/2024 which was not previously reported to the Dept. R1 previously had a fall prior to the ankle swelling, report was not provided to the Dept.

SAC & Basuny Eldaouch were informed of the reporting requirements. Citation was issued under Title 22, Division 6, Chapter 8.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Basuny Eldaouch.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/27/2024 01:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidenced by:
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Administrator will make sure reports are submitted within 7 days. Administrator will provide a statement to LPA.
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Based on observation, interview, & record review the licensee did not comply with the regulation listed above. LPA was provided internal incident reports which were not reported to the Dept.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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