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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200375
Report Date: 04/10/2024
Date Signed: 04/10/2024 01:34:28 PM


Document Has Been Signed on 04/10/2024 01:34 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BETHANY HOME CONCORDFACILITY NUMBER:
079200375
ADMINISTRATOR:ARPAD NAGYFACILITY TYPE:
740
ADDRESS:3815 CONCORD BLVD.TELEPHONE:
(925) 640-6403
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 6DATE:
04/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Telesha Clarke, ManagerTIME COMPLETED:
01:45 PM
NARRATIVE
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On 04/10/2024 Licensing Program Analysts (LPA) J. Clancy-Czuleger and A. Gharachorloo arrived unannounced to conduct a Case Management. LPA met with Telesha Clarke, House Manager.

While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20240409090155) on 04/10/2024, LPA observed that there were two staff members listed on the LIC 500 that are not associated to the facility.. LPAs verified that S1 and S2 are fingerprint cleared but not associated. During the investigation LPAs observed S3 enter the house, S4 stated that they were a new hire and were doing on boarding. LPAs interviewed staff and residents and found that S3 has been at the facility working before today.

During the investigation LPAs asked for the medication logs of each dosage given to the residents. S4 stated that they were behind on those logs as they were doing it electronically and the system crashed and she was having to print them out and do it by hand.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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 04/10/2024 01:34 PM - 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BETHANY HOME CONCORD
FACILITY NUMBER: 079200375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
CCR
87355(e)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Manager will ensure staff has a fingerprint clearance and is associated to facility before returning to work.

A civil penalty of $1000 has been assessed
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Based on observation, the licensee did not comply with the section cited above by having two staff who are not associated and one staff who is not associated which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
04/12/2024
Section Cited
CCR87355(d)

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All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
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The individual has been removed from the facility and will not return until they are fingerprint cleared and associated to the facility. Proof of correction will be sent to CCLD by POC date

A civil penalty of $500 has been assessed
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/10/2024 01:34 PM - 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BETHANY HOME CONCORD
FACILITY NUMBER: 079200375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
CCR
87465(d)(3)

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If the resident is unable to determine his/her own need for a prescription or nonprescription ... (3) The date and time the medication was taken, the dosage taken, ...shall be documented and maintained in the resident's facility record.
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The facility agrees to review the regulation and complete the medication logs for all residents. Proof of correction will be sent to CCLD by POC date
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Based on observation the licensee did not comply by not having a log of dosages taken for each resident.
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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