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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700444
Report Date: 11/07/2024
Date Signed: 11/13/2024 07:15:52 AM

Document Has Been Signed on 11/13/2024 07:15 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BETHEL ASSISTED LIVINGFACILITY NUMBER:
502700444
ADMINISTRATOR/
DIRECTOR:
MELISSA ORELLOFACILITY TYPE:
740
ADDRESS:2325 & 2345 SCENIC DRTELEPHONE:
(209) 577-1901
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 125TOTAL ENROLLED CHILDREN: 0CENSUS: 108DATE:
11/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Maria Castillo Padilla TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 11/07/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Representative (FDR), Maria Castillo-Padilla and explained the purpose of the visit. The purpose of this visit was to follow up on an incident report received by the department on 11/05/2024.

Current census was 108. A brief interview with FDR Padilla was conducted.

On 11/05/2024, the department received a Special Incident Report (SIR) from this facility stating that on 11/04/2024, a medication technician provided the wrong medication for R1. R1 was provided Lorazepam 1mg intended for another resident instead of their routine medication of Alprazaam 0.5mg.
The Medication Technician notified facility management, who called poison control and provided directive to put the resident on a 72 hour observation period. The facility took the resident's vitals and additional check ins were conduct as requested by poison control.
The facility will plan to conduct additional training on the 7 rights of medication as well as supplemental training for S1.


Based on the information gathered during the course of this visit, per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, and a copy of the report will be given.
Lisa RiosTELEPHONE: (916) 969-9685
Arielle PascuaTELEPHONE: (916) 862-5907
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 11/13/2024 07:15 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BETHEL ASSISTED LIVING

FACILITY NUMBER: 502700444

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(4) The licensee shall assist residents with self-administered medications as needed.
This is not met as evidenced by:
Based on interview and record review, the facility did not ensure that R1 was provided the correct medication at the time of med pass.
Deficient Practice Statement
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POC Due Date: 11/08/2024
Plan of Correction
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Licensee/Administrator shall provide a statement of acknowledgement and correction to the LPA by the POC date of 11/08/2024. In addition, training shall be conducted no less than an hr of duration. A copy training shall be provided to the LPA upon completion.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa RiosTELEPHONE: (916) 969-9685
Arielle PascuaTELEPHONE: (916) 862-5907

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024

LIC809 (FAS) - (06/04)
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