502700444-4-3-2024-27-AS-KHOS-D47NME-20240410103500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700444
Report Date: 04/02/2024
Date Signed: 04/03/2024 10:42:37 AM

Unsubstantiated

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
12/04/2023 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231204084247

FACILITY NAME:	BETHEL ASSISTED LIVING		FACILITY NUMBER:	502700444
ADMINISTRATOR:	MITCHAEL WORD		FACILITY TYPE:	740
ADDRESS:	2325 & 2345 SCENIC DR		TELEPHONE:	(209) 577-1901
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	125	CENSUS: 112	DATE:	04/02/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Michelle Orello		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure reporting requirements are being followed
Facility staff mismanages resident medication

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 04/02/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Melissa Orello and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above.

Current census was 112. A brief interview with FDA Orello was conducted.

Staff do not ensure reporting requirements are being followed.
It was alleged that the staff do not ensure reporting requirements are not being followed. During the course of this investigation LPA conducted interviews and reviewed facility documentation. Based on interviews conducted, 7 out 7 staff state that they receive annual training on reporting requirements and are aware what needs to be reported. 7 out 7 staff state that when an incident happens with a resident they fill out the incident form and will send it to management to review and sent to the department via fax.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

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 2

Control Number 27-AS-20231204084247

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: BETHEL ASSISTED LIVING	FACILITY NUMBER: 502700444
	VISIT DATE: 04/02/2024

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

2 out 7 staff members state that once reviewed by management they send the incident report within 10 days of occurrence via fax and notify the LPA via email if the fax is unsuccessful. LPA reviewed facility documentation to review incident reports for the past 3 months and was provided copies of all and any incident reports dating back to September 2023. It was observed by this LPA that the facility is properly reporting to all parties involved with supporting documents sent out as well. Based on the information gathered it is unclear of the staff do not ensure reporting requirements are being following.

Facility staff mismanages resident medication.
It was alleged that facility staff mismanages resident medication. During the course of this investigation, LPA conducted interviews, toured the facility and reviewed facility documentation. Based on interviews conducted, 7 out 7 staff members deny that they have mismanaged any resident medication. 7 out 7 staff members state that they are confident in ensuring that each resident is provided with the right and correct amount of medication. On 12/12/2023 and 03/12/2024 LPA Pascua observed 4 separate medication passes in which observed that the Medication Technicians were providing the residents with the correction medication. LPA observe medication stored at the facility to match physicians orders and medication dispensing logs. LPA Pascua reviewed medications on 12/12/2023 and 03/12/2024 which reflected that the facility was providing medication as ordered by the physician. Based on the information gathered, it is unclear if the facility staff mismanaged resident medication.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations 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. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2