247200745-5-24-2021-24-AS-MHON-C3CPDL-20210525111340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247200745
Report Date: 04/14/2021
Date Signed: 05/24/2021 01:28:07 PM

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
03/04/2021 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20210304105530

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: 48	DATE:	04/14/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Julia Fonseca-Administrator		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide resident's designated representative a copy of resident's records

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this date, Licensing Program Analyst (LPA) D. Ayers contacted the facility to deliver complaint findings via telephone due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call with Administrator Julia Fonseca.

During the course of the investigation, the Department conducted interviews and reviewed records. Staff 1(S1) stated that the requested records were sent the the designated representative on 3/16/2021. The designated representative confirmed that the requested records were received on 3/16/2021.

The allegation is Unfounded. No Deficiencies cited. Exit interview conducted, and copy of this report was provided to the Administrator via email.

Unfounded

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: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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 2