247200745-2-12-2021-24-AS-AXIG-BZFM2W-20210325091409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247200745
Report Date: 02/11/2021
Date Signed: 02/12/2021 10:18:41 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
11/03/2020 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20201103093443

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:	11:35 AM

ALLEGATION(S):

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Staff neglect resulted in a resident being hospitalized
Staff failed to ensure resident was properly fed while in care

INVESTIGATION FINDINGS:

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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 Julia Fonseca and Lucinda Fonseca.

During the course of the investigation, the department conducted interviews, reviewed records, and conducted a virtual tour of the facility. On 10/23/2020, Resident 1(R1) was hospitalized due to open wounds which R1 had developed while at the facility. Staff 1(S1), Staff 2(S2), Staff 3(S3), Staff 4(S4), and Staff 5(S5) all stated that they were aware that R1 had open wounds while he was at the facility. The Responsible Party (RP) for R1 stated that they were not informed of the wounds prior to 10/23/2020.

Continued on attached 9099C

Substantiated

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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Control Number 24-AS-20201103093443

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
	VISIT DATE: 02/11/2021

NARRATIVE

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S1, S2, S3, S4, and S5 stated that R1 had a noticeable weight loss that was possibly due to him not eating his meals. Facility Administrator stated that R1 was very skinny during his last months at the facility due to not eating a lot. According to medical reports, R1 weighed 146 pounds on 9/09/2020, and 102 pounds on 10/23/2020. The medical report from 10/23/2020 also stated that R1 had severe malnutrition in the context of chronic illness that was present on admission. The allegations are substantiated.

See attached 9099D for citation issued in accordance with California Code of Regulations, Title 22.

Immediate Civil Penalty is assessed.

Exit interview conducted via telephone and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) provided to the licensee via email. A read receipt confirms the licensee receives these documents.

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20201103093443

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: 02/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/18/2021 Section Cited CCR 87464	1 2 3 4 5 6 7	87464 Basic Services(d): A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457...and providing the other basic services...either directly or through outside resources. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to submit a plan on how to prevent pressure injuries, how to care for pressure injuries, communicate with families and responsible parties, and how to ensure residents receive proper nutrition.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the licensee did not ensure that facility staff were providing adequate care to R1, which resulted in R1 being hospitalized on 10/23/2020 with multiple pressure injuries and severe malnutrition. An immediate civil penalty of $500 is assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. See form LIC 421IM for more detail.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC9099 (FAS) - (06/04)

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