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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200309
Report Date: 09/28/2023
Date Signed: 09/28/2023 03:21:56 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230626160238
FACILITY NAME:BETHANY HOMEFACILITY NUMBER:
079200309
ADMINISTRATOR:NAGY, ARPADFACILITY TYPE:
740
ADDRESS:2201 ROCKNE DRIVETELEPHONE:
(925) 640-6403
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 5DATE:
09/28/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Telesha ClarkeTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unstageable pressure injuries due to staff neglect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/28/2023 at 2:15 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Administrator Telesha Clarke.

During the complaint visit LPA obtained information, reviewed records, collected documents, and interviewed staff. It was alleged a resident sustained an unstageable pressure injury while in care. During an interview with S1 they stated that they did have a resident who had a pressure injury during that time frame. This resident was on hospice when the ulcer developed and was being addressed in the hospice care plan that the facility was following.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
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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