502700444-6-14-2021-27-AS-SDOB-C4JMTC-20210702095319

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700444
Report Date: 06/14/2021
Date Signed: 06/14/2021 03:55:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2021 and conducted by Evaluator Arlene D Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210407081552

FACILITY NAME:	BETHEL ASSISTED LIVING		FACILITY NUMBER:	502700444
ADMINISTRATOR:	VIVIANO, KIMBERLY M		FACILITY TYPE:	740
ADDRESS:	2325 & 2345 SCENIC DR		TELEPHONE:	(209) 577-1901
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	125	CENSUS: 120	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Kim Viviano		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility has bed bug infestation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Arlene Garcia met with ED, Kim Viviano to discuss the allegation on 6/14/2021. ED agreed to meet with LPA.

The initial 10 day visit was conducted on 4/15/2021.
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During the course of the investigation LPA interviewed ED who confirmed the facility had bedbugs.ED provided the invoice from pest control. Based on a information provided
through interviews, the allegation that the facility has bedbugs was Substantiated.

This agency has investigated the allegation notice and has found the allegation to be Substantiated meaning that there was a preponderance of evidence to prove the allegation was true as reported.

The following deficiency was cited per Title 22 Provision 6 of the CA Code of Regulations. An exit interview was conduct with ED.

A copy of this report along with appeal rights was provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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 27-AS-20210407081552

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/14/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation was not met as evidence by:	1 2 3 4 5 6 7	Deficiency corrected at time of visit. Administrator provided proof of treatment by pest control.
	8 9 10 11 12 13 14	The licensee did not ensure that the facility was maintained clean, that the facility was safe and sanitary for the safety and well being of residents.Based on interviews, the facility had bedbugs.This poses a potential risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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