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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 390312809
Report Date: 02/15/2024
Date Signed: 02/20/2024 05:17:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231103103214
FACILITY NAME:BETH HAVENFACILITY NUMBER:
390312809
ADMINISTRATOR:JOSE VENTURAFACILITY TYPE:
740
ADDRESS:368 S. WILMA AVE.TELEPHONE:
(209) 599-7670
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:59CENSUS: 43DATE:
02/15/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jose VenturaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not seek timely medical care for resident

Staff did not notify resident's authorized representative of injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Unannounced complaint visit made out to this facility on 02/13/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Jose Ventura. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 43 residents.
The purpose of this complaint visit was to deliver the findings from this investigation to this facility, and its representatives, in regards to the above allegations.
Based on interviews conducted throughout the course of this investigation, it was learned that resident R1 sustained a fall while participating in an indoor activity. It was learned that R1 attempted to stand up during a facility supervised game and rolled R1's ankle. This fall took place on 10/17/2023.
Based on a review of the forms and documents related to R1's fall that took place on 10/17/2023, several facility staff notated that R1's left ankle was swollen. These notes were observed to have been documented on 10/19/2023, 10/22/2023, 10/23/2023, 10/24/2023, and 10/25/2023. It was learned that R1 was not taken to see a licensed medical professional for an evaluation until almost 2 weeks later on 10/30/2023.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20231103103214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BETH HAVEN
FACILITY NUMBER: 390312809
VISIT DATE: 02/15/2024
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
26
27
28
29
30
31
32
Based on interviews conducted, it was learned that this incident was not reported to the responsible parties for R1 when R1 initially sustained the fall on 10/17/2023 and was suffering with a swollen left ankle. It was learned that the responsible parties were not made aware of the incident and reason for the hospital visit until the actual date of the appointment on 10/30/2023.
It was further learned that this facility, and it's representatives, admitted that there was a breakdown in communication with R1 and R1's responsible parties in connection to this fall that took place on 10/17/2023 and they should have been informed in a timely manner.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated Administrator at this time.

This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties as well.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231103103214

FACILITY NAME:BETH HAVENFACILITY NUMBER:
390312809
ADMINISTRATOR:JOSE VENTURAFACILITY TYPE:
740
ADDRESS:368 S. WILMA AVE.TELEPHONE:
(209) 599-7670
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:59CENSUS: 43DATE:
02/15/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jose VenturaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained an unexplained fracture while in care.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Unannounced complaint visit made out to this facility on 02/15/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Jose Ventura. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 43 residents.
The purpose of this complaint visit was to deliver the findings from this investigation to this facility, and its representatives, in regards to the above allegations.
Based on interviews conducted throughout the course of this investigation, it was learned that resident R1 sustained a fall while participating in an indoor activity. It was learned that R1 attempted to stand up during a facility supervised game and rolled R1's ankle. This fall took place on 10/17/2023.
It was learned that the facility lead nurse was notified about the fall and assessed R1 for any visible signs of injury or pain. The lead nurse determined that R1 did not complain of any pain or discomfort even after walking several steps as instructed by the lead nurse. The lead nurse then concluded that R1 was not suffering from any fractures or broken bones so R1 was not taken to the hospital at that time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20231103103214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BETH HAVEN
FACILITY NUMBER: 390312809
VISIT DATE: 02/15/2024
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
26
27
28
29
30
31
32
Based on a review of the medical records, it was not discovered that R1 had suffered a fracture of R1's left foot until 10/30/2023 when R1 was taken to the hospital by R1's responsible party.
An x-ray was performed since R1's left ankle was swollen and it was discovered that R1 had, in fact, suffered a fracture of the distal fibula in R1's left foot.
Since almost two weeks had elapsed before this x-ray was performed, it was not definitive whether the initial fall on 10/17/2023 was the leading cause for the fracture since medical treatment was not sought at the time of the fall at this facility.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231103103214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BETH HAVEN
FACILITY NUMBER: 390312809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2024
Section Cited
CCR
87468.1(a)(8)
1
2
3
4
5
6
7
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
1
2
3
4
5
6
7
The facility designated Administrator stated that all facility personnel will undergo, and complete, training on the topic of Proper Reporting Requirements for no less than (1) hour in duration.
A statement of correction, along with proof of training, will be completed and submitted into
8
9
10
11
12
13
14
This facility was found to be deficient as evidenced by a records review in which this facility, and it's representatives and staff, did not properly notify the responsible parties of a resident who sustained an injury posing an immediate threat to the Health, Safety, and Personal Rights of residents in care.
8
9
10
11
12
13
14
CCL by the due date. Proof of training will include name of trainer, topic, and list of attendees from this facility.
Type A
02/22/2024
Section Cited
CCR
87466
1
2
3
4
5
6
7
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or
1
2
3
4
5
6
7
The facility designated Administrator stated that all facility personnel will undergo, and complete, training on the topic of Observation of the Resident for no less than (1) hour in duration.
A statement of correction, along with proof of training, will be completed and submitted into
8
9
10
11
12
13
14
a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This facility was found to be deficient as evidenced by a records review in which this facility, and it's representatives and staff, did not properly seek medical attention after a resident sustained an injury which posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
8
9
10
11
12
13
14
CCL by the due date. Proof of training will include name of trainer, topic, and list of attendees from this facility.
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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5