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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700444
Report Date: 09/15/2023
Date Signed: 09/20/2023 10:02:27 AM


Document Has Been Signed on 09/20/2023 10:02 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
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: 108DATE:
09/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mitchael WordTIME COMPLETED:
01:00 PM
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On 09/15/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA was greeted by Maria Castillo-Padilla and explained the purpose of the visit. Shortly after, LPA met with Facility Designated Administrator, Mitchael Word.

Current Census was 108. A brief interview with FDA Word and Padilla was conducted.

The purpose this visit is to follow up on an incident report that was received by the department on 08/18/2023. The incident report states that R1 was administered insulin when it was not needed. Based on interviews conducted, it was learned that R1 was currently receiving services home Community Hospice and was working with the community to find the correct dosage of insulin. It was stated that the latest order was to hold insulin when the resident's blood sugar was under 200. Based on records, it was learned that on the day of the incident the resident's blood sugar tested at 89.

LPA reviewed facility records and found that after the incident the facility has spoken to the Medication Technician responsible for the error as well as provided training for Insulin and medication management to all staff members within the last four weeks.

Based on the information gathered today, a Technical Violation will be provided for Section 87465(a)(1).

An exit interview was conducted and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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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