247200745-7-8-2021-24-AS-SPIY-C4YNMK-20210716103512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247200745
Report Date: 03/30/2021
Date Signed: 07/08/2021 06:34:23 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
12/02/2020 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20201202132410

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: 51	DATE:	03/30/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Julia Fonseca-Administrator		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple falls while in care resulting in injury.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
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 Julia Fonseca.

During the course of the investigation, the Department conducted interviews and reviewed records. On 11/20/2020, Resident 1(R1) was transferred from the adjacent Skilled Nursing Facility back to the Residential Care facility for the Elderly(RCFE). While at the RCFE, on 11/25/2020, R1 fell and sustained injuries for which they were hospitalized.

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

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: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

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

Control Number 24-AS-20201202132410

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: 03/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/13/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services:(f)shall at a minimum include:(1)Care and supervision as defined...Health and Safety Code section 1569.2(c)"Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to develop a plan to provide adequate supervision for residents who are fall risks.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the licensee did not take necessary measures or provide adequate supervision to prevent R1 from sustaining a fall on 11/25/2020.	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: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2