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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700545
Report Date: 11/08/2023
Date Signed: 11/08/2023 11:56:11 AM


Document Has Been Signed on 11/08/2023 11:56 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: 5DATE:
11/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator, David BostanchyanTIME COMPLETED:
12:00 PM
NARRATIVE
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On 11/08/23, LPA Bains conducted an unannounced case management visit to the facility to follow up on an incident which happened at facility on 05/31/23 related to 2 facility staff members. LPA met with administrator, David Bostanchyan and explained the purpose of today’s visit.

The department conducted a record review to investigate this incident. Based on the records reviewed, it has been determined that the facility did not report an incident to the Department where staff, S1 made inappropriate sexual conduct to staff S2 on 05/31/23. Law enforcement was called and S1 got arrested due to this incident. Per facility records, S1 and S2 were ‘live-in’ staff at the time of incident. The facility should have reported this incident to CCL as required by Title 22. Although this incident did not involve residents but S1 and S2 were on duty at the facility and were responsible for the care and supervision of the residents ultimately putting the residents’ health and safety at risk.

Additionally, it has been concluded that administrator was aware about this incident which happened at the facility between staff, S1 and S2 but administrator did not comply with reporting requirement.

During today's visit, administrator stated that facility send SIR (LIC624) for this incident to CCL via Fax but facility could not provide any verification to prove it when LPA requested.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page.

Exit interview conducted. Appeal Rights and copy of this report has been provided to facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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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Document Has Been Signed on 11/08/2023 11:56 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: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2023
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D) -Reporting Requirement- Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse …. This requirement is not met as evidenced by;
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Licensee shall send a written statement to CCL of understanding of regulation for 87211 for reporting requirements and shall do training with staff. POC documents should be sent to CCL by POC date-11/09/23.
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Based on the records reviewed, it has been determined that the facility did not report an incident where staff, S1 made inappropriate sexual conduct to staff, S2 on 05/31/23 which poses an immediate health and safety risks to residents in care.
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Type A
11/09/2023
Section Cited
CCR87405(d)(2)

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87405- Administrator - Qualifications and Duties(d)(2)- Knowledge of and ability to conform to the applicable laws, rules and regulations….. This requirement is not met as evidenced by;
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Administrator agreed to submit a self-certification of understanding the regulation ,87405 (d)(2) and will make sure to report any reportable incidents to CCL as required and submit proof to CCL by POC date-11/09/23.
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Based on the records reviewed and interviews, it has been determined that the administrator did not report an incident where staff, S1 made inappropriate sexual conduct to staff, S2 on 05/31/23 which poses an immediate health and safety risks to residents in care.
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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: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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