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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700545
Report Date: 07/23/2024
Date Signed: 07/23/2024 11:10:33 AM


Document Has Been Signed on 07/23/2024 11:10 AM - 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:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Assistant Administrator, Jacob BostanchyanTIME COMPLETED:
11:15 AM
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) Talwinder Bains arrived on 07/23/24 to conduct the annual inspection. LPA met with Assistant Administrator, Jacob Bostanchyan (Jacob) and explained the purpose of today's visit.
During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed two (2) residents and two (2) staff files and found all required documents in residents files but missing CPR/FIRST AID certification in staff, S1s file and citation has been issued as indicated on LIC809-D.

LPA and Jacob toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Hot water temperature was observed to be 109 degrees F, which is within the regulation range of 105-120 degree. Inside temperature was 76 degree F. Facility was clean and well organized. All required postings were observed. Facility is conducting quarterly fire and disaster drill as required.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 08/05/24.

LPA reviewed medications of two (2) residents (R1,R2) comparing with physician orders and issues were observed with R1s medications management. LPA observed that facility's only Fire Extinguisher was last serviced on 10/19/2022. Deficiencies were observed and cited per Title 22 Regulations during this visit as listed on LIC809-D. Exit interview conducted ,appeal rights and copy of this report was provided to Jacob.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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 3


Document Has Been Signed on 07/23/2024 11:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: BETHESDA SENIOR CARE
FACILITY NUMBER: 342700545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and staff interview, it was found that resident, R1 medications, Losartan 25 mg/90 tablets- 1 tablet daily with start date 05/03/24 ( 2 extra tablets ) ,Mirtazapine 15mg/90 tablets- 1 tablet daily with start date 05/03/24 ( missing 3 tablets) , Buspirone, 5 mg/30 tablets, 1 tablet/2 times a day with start date 06/07/24 (10 tablets extra), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
1
2
3
4
Administratoe shall submit letter of understanding of this Regulation and will conduct staff training regarding medication management and send proof to Department. All POC documents are due by 07/24/24.
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: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/23/2024 11:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: BETHESDA SENIOR CARE
FACILITY NUMBER: 342700545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs observations, facility has one fire extinguisher which was last serviced in 10/19/2022 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
1
2
3
4
 Licensee agrees to have the fire extinguisher serviced and will send a receipt and/or photograph of the fire extinguisher having been serviced. The receipt/photograph will be due by the POC due date - 08/05/24.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff interview and record review, the licensee did not comply with the section cited above as staff ,S1, does not have active CPR/FIRST AID certification as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
1
2
3
4
Licensee shall ensure that staff, S1 and all other staff members have Active CPR/FIRST AID certification as required and send proof to Department by POC due date -08/05/24.
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: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3