342700545-3-23-2022-25-AS-KHOS-CCYP9G-20220329110708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700545
Report Date: 03/22/2022
Date Signed: 03/23/2022 03:58:40 PM

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
07/13/2021 and conducted by Evaluator Jacob Williams

COMPLAINT CONTROL NUMBER: 25-AS-20210713163656

FACILITY NAME:	BETHESDA SENIOR CARE		FACILITY NUMBER:	342700545
ADMINISTRATOR:	BOSTANCHYAN, DAVID		FACILITY TYPE:	740
ADDRESS:	8874 NIMBUS WAY		TELEPHONE:	(916) 627-0305
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	6	CENSUS: 6	DATE:	03/22/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	David Bostanchyan		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Licensee did not provide at least 60 days prior written notice to the resident of any rate or rate structure change.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jacob Williams, arrived at facility to deliver findings on allegations listed above. Prior to arriving, LPA self-screened for having no known symptoms or exposure, followed facility's screening protocols, wore a surgical mask and maintained distance during the visit.

Throughout the investigation LPAs Lusby and Williams reviewed resident documents and conducted interviews. It was learned that in June 2021 R1 had verbally told Administrator that he was moving out of the facility. Admission agreement states a 30 day eviction notice is to be given in writing from resident. A 30 day eviction notice was never given. Shortly after telling Administrator he was going to leave, R1 decided he was going to remain at facility. During this time, Administrator states he had a new resident lined up from a referral agency who would pay a higher monthy fee than R1 was paying.

Continuation on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

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 25-AS-20210713163656

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
	VISIT DATE: 03/22/2022

NARRATIVE

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Beginning July 2021 R1 was charged the higher amount ($1400 more than the original agreed-upon monthly rate) without issuing a 60 day notice of an increase in fees. According to Title 22, Division 6 Health and Safety Code 1569.655(a): If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident.

Based on information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC9099D. Administrative actions may occur.

Exit interview conducted, copies of report provided with appeal rights. Printer had error so documents are being emailed.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210713163656

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: 03/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/05/2022 Section Cited HSC 1569.655(a)	1 2 3 4 5 6 7	1569.655 Increase in fee rates; 60 days’ written notice (a) If a licensee... increases the rates of fees... the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a description of the additional costs.	1 2 3 4 5 6 7	Administrator to review health and safety code 1569.655 Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase. Administrator to send in a statement of understanding of rate increases. Statement to be sent into CCL by 04/05/22.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record review CCL was able to determine licensee increased resident rate without notifying R1 or his representatives 60 days in advance, which poses a potential health risk to residents in care.	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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

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