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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247200745
Report Date: 10/21/2024
Date Signed: 10/21/2024 10:44:14 AM


Document Has Been Signed on 10/21/2024 10:44 AM - 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: DATE:
10/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Administrator- Basuny EldaouchTIME COMPLETED:
11:00 AM
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On 10/21/24 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management visit regarding R1. LPA introduced herself and explained the reason for the visit. LPA met with Administrator Basuny Eldaouch.

The Dept. received a report on 10/6/24 regarding an incident that happened on 10/3/24 with R1. R1 was taken to the hospital and had colon surgery. LPA reviewed R1's chart to see the reason leading to the surgery and if there is a change in condition for R1.

LPA spoke with Administrator who stated R1 did not return to the facility and was sent to a skilled nuring facility. LPA also spoke with S1. S1 stated R1 was not eating for 2 days and was sent to the hospital. S1 stated at the hospital it was found R1 had a blockage, prior being sent to the hospital R1 did not display any other complications or new health conditions.

R1's chart was reviewed and LPA did not observe any discrepancies. No citation was issued.


Exit interview was conducted and a copy of this report LIC809 was provided to Administrator Basuny Eldaouch.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024
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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