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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700444
Report Date: 09/23/2022
Date Signed: 09/23/2022 03:03:24 PM


Document Has Been Signed on 09/23/2022 03:03 PM - It Cannot Be Edited

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:MITCHAEL WORDFACILITY TYPE:
740
ADDRESS:2325 & 2345 SCENIC DRTELEPHONE:
(209) 577-1901
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:125CENSUS: 105DATE:
09/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sara Poulos, Mitch Word, and Maria Casillo-Padilla.TIME COMPLETED:
01:00 PM
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On 09/23/2022 at 11:15 AM, Licensing Program Analyst (LPA) Arielle Pascua arrived at the facility unannounced to conduct a case management visit. LPA Pascua met with Facility Designated Representative, Sara Poulos and explained the purpose of the visit. The purpose of this visit was to conduct a case management visit on an SIR that was sent in to the department on 09/16/2022.
The SIR that was received by the department stated that there was suspected abuse from Staff 1(S1) regarding Resident 1(R1) who was currently on hospice services. LPA Pascua interviewed Maria Castillo-Padilla, Sara Poulos and CEO, Mitch Word and it was learned that the facility conducted an internal investigation regarding the incident. Upon the investigation, S1 was suspended indefinitely until a complete investigation by the facility was conducted. Per interviews with facility management, It was learned that on 09/07/2022, staff notified hospice that they have seen a decline in R1's eating habits and was not taking scheduled medication. Shortly after, a hospice nurse visited R1 and notified the facility staff that the resident was in the stages of transitioning and could transition within the next 24 hours. R1 passed away on 09/08/2022 at 4:27am. On, 09/14/2022, S1 met with S2 and S3, regarding an incident that happened between S1, S4 and R1. It was stated that S1 and S4 were in the room with R1 while S4 was providing R1 water. S1 observed S4 pinch R1's nose and stated that they provide water to the residents so that they can transition faster. The facility conducted an internal investigation shortly after. It was learned during this investigation that S4 was interviewed and denied any abuse towards R1. S4 stated that they went into the room to provide R1 oral care to swab R1's mouth. Due to there being lack of evidence of suspected abuse and were notified after R1s death, the facilities internal investigation concluded that S1 did not have part in any abuse towards R1 and their death. Since last week, S4 has been terminated due to other misconduct during their tenure at the facility.
LPA Pascua obtained facility reports and R1's physicans report. Based on interview and records review there were no deficiencies that were cited during this case management visit. LPA Pascua will come at a later time if further follow up is needed.
A copy of this report was provided to the facility and an exit interview was conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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