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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700545
Report Date: 05/13/2024
Date Signed: 05/13/2024 01:11:24 PM


Document Has Been Signed on 05/13/2024 01:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
05/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Administrator, David BostanchyanTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/13/24 to do case management visit. LPA met with administrator David Bostanchyan and explained the purpose of the visit.

Department followed up on Incident Report (IR) sent by facility on 05/08/24 stating that resident, R1 had a wrist fracture which was diagnosed on 05/08/24 after staff noticed swelling in R1s right hand on 05/06/24 around 11am and notified administrator. IR indicated that administrator notified R1s family and doctor regarding this hand swelling on 05/06/24. R1s doctor ordered lab work and X-RAY and results dated- 05/08/24 indicated wrist fracture on R1s right wrist .Department conducted interviews with resident, R1 ,administrator and 1 staff member regarding this incident.

At this time, this case is under review and department will do follow up as needed.
No citations were issued per Title 22 Regulations.
Exit interview conducted and copy of the report left at facility.







SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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