342700545-7-19-2022-25-AS-LMUZ-CGVRR9-20220801131442

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700545
Report Date: 07/19/2022
Date Signed: 07/19/2022 01:35:53 PM

Substantiated

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
02/02/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20220202142731

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:	07/19/2022
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Jacob Bostanchyan, Assistant Administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Resident was left unattended without care and supervision.

Facility did not notify resident's responsible party that resident left the community.

INVESTIGATION FINDINGS:

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On 7/19/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Assistant Administrator, Jacob Bostanchyan, to deliver findings regarding a complaint investigation into the allegations listed above. LPA wore an N-95 mask and was screened by facility upon entry. Facility staff wore masks while on the premises.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Resident was left unattended without care and supervision.

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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-20220202142731

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: 07/19/2022

NARRATIVE

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Interviews with relevant parties indicated that, on 2/1/2022, owner of facility dropper resident (R1) off at their house, which was 20-30 percent damaged due to a fire. Neighbors saw R1 inside the house by themselves and brought them back to their home. The police were then contacted (interviews are inconsistent with who contacted the police).

Interview with Administrator indicated that R1 was taken to home by Administrator to retrieve a cell phone charger, which was found at their home. Administrator stated that they left R1 with the their neighbors while they went around the corner to get gas. Administrator stated that they were gone for 45 minutes and returned to the neighbors that had R1. When Administrator returned to the home, they found police had been contacted. Administrator stated that they did not know R1’s neighbors prior to excursion.

R1’s Physician’s Report (LIC 602) dated for 12/16/2021 indicated that R1 has a primary diagnosis of dementia and is unable to leave the facility unassisted, with a note indicating that “due to dementia patient at risk for not remembering the way back.”

Allegation: Facility did not notify resident's responsible party that resident left the community.

Interview with relevant party indicated that they were not notified that R1 was leaving the facility and did not know of their absence until notified by R1’s neighbors.

As of inspection conducted on 7/19/22, an incident report has not been completed for incident that occurred on 2/1/2022.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with Assistant Administrator. A copy of this report and appeal rights were provided. The Assistant Administrator’s signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220202142731

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: 07/19/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/20/2022 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will complete a statement of understanding regarding regulation 87705 and submit statement to Department by POC due date of 7/20/2022.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure that resident (R1) was properly supervised during outing, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 08/03/2022 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish (...) (1) A written report (...) to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (...) (D) Any incident which threatens the welfare, safety or health of any resident, such as (...) unexplained absence of any resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will complete a statement of understanding regarding regulation 87211 and submit statement to Department by POC due date of 8/3/2022.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not report R1's unsupervised absence from the facility, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC9099 (FAS) - (06/04)

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