<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700545
Report Date: 07/08/2021
Date Signed: 07/08/2021 05:34:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: DATE:
07/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:David Bostanchyan, administratorTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 07/08/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator David Bostanchyan and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment.

LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entry.

LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, staff rooms, bathrooms, laundry room, and outdoor area. During tour LPA observed medications unlocked and accessible to residents in two (2) resident bedrooms. LPA reviewed three (3) residents records and observed that one (1) is not allowed to store their medications, one (1) is able to store medications with assistance and one (1) did not have a completed medical assessment in their file.

LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

Deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report and appeal rights to be emailed to administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one (1) out of three (3) records reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2021
Plan of Correction
1
2
3
4
Licensee to schedule an appointment for resident to obtain a current physican's report for resident, once LIC 602 is obtained licensee to send a copy of to CCL. Proof of correction due by 07/22/2021.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)(B)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in two (2) of three (3) residents records reviewed and two (2) of five (5) rooms toured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2021
Plan of Correction
1
2
3
4
Licensee removed medications from rooms during inspection. Licensee to review regulation 87465 Incidental Medical and Dental Care and send letter of understanding regarding the parameters that must be met for residents to store their own medications. Plan of correction due to CCL by 07/09/2021.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6