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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700444
Report Date: 06/04/2021
Date Signed: 06/07/2021 11:16:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BETHEL ASSISTED LIVINGFACILITY NUMBER:
502700444
ADMINISTRATOR:VIVIANO, KIMBERLY MFACILITY TYPE:
740
ADDRESS:2325 & 2345 SCENIC DRTELEPHONE:
(209) 577-1901
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:125CENSUS: 101DATE:
06/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kim Viviano, Executive Director (ED)TIME COMPLETED:
04:06 PM
NARRATIVE
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On 6/4//2021, Licensing Program Analyst (LPA) Arlene Garcia and (LPA) Albert Johnson conducted an unannounced case management visit on this date. LPAs met with (ED) Kim Viviano and explained the purpose of today's visit.

Based on interviews and record review, LPAs observed that the ED did not notify Community Care Licensing (CCL) of the incident that occurred with R1 and S1 on 4/19/2021.

Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview conducted with Administrator. Copy of LIC 809, LIC 809-D, and appeal rights will be sent via email. Failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BETHEL ASSISTED LIVING
FACILITY NUMBER: 502700444
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2021
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Based on interview with ED, LPAs observed ED was made aware of possible fraudulent charges by residents family member on 4/19/2021. LPAs obsevred ED reported but not until the incident was substantiated with an internal invesitgation. This posseses a potential threat to health and safety and 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2021
LIC809 (FAS) - (06/04)
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