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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700545
Report Date: 06/18/2021
Date Signed: 06/18/2021 10:10:18 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2020 and conducted by Evaluator Michael Smith
COMPLAINT CONTROL NUMBER: 27-AS-20201217123309
FACILITY NAME:BETHESDA SENIOR CAREFACILITY NUMBER:
342700545
ADMINISTRATOR:BOSTANCHYAN, DAVIDFACILITY TYPE:
740
ADDRESS:8874 NIMBUS WAYTELEPHONE:
(916) 627-0305
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 5DATE:
06/18/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Amanda LaRanceTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Resident had a physical altercation with another resident resulting in injury
INVESTIGATION FINDINGS:
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Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore an N-95 respirator and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Amanda LaRance.

Facility had 3 staff members present in the facility, however all 3 staff were in the garage unloading groceries when this incident happened. Facility was aware that R1's behavior had been agitated for the previous 3 days. Since there were 3 staff present, a minimum of 1 staff member should have stayed indoors to provide care and supervision. Based on the facts and circumstances of this incident, this allegation is SUBSTANTIATED.

As a result of this investigation, LPA finds the allegation that resident had a physical altercation with another resident resulting in injury to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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 27-AS-20201217123309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BETHESDA SENIOR CARE
FACILITY NUMBER: 342700545
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2021
Section Cited
CCR
87411(a)
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87411-Personnel Requirements-General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on documentation, licensee did not provide adequate care and supervision when 1 resident battered
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Facility shall submit a written plan of action to prevent this type of harm from occurring in the future. Facility shall submit this written plan to the LPA to clear this deficiency. This shall be done within 5 days.
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another resident. Facility is in violation of this section. This poses an immediate health and safety risk to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC9099 (FAS) - (06/04)
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