BETHESDA HOME

Official classification

Type B

Official code

87156(a)

Regulation authority

CCR

What the official deficiency says

87156 Licensing Fees: (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. provides ....after initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. -This requirement is not met as evidenced by: -Based on review, the licensee did not comply with the section above in not paying the annual fee which was due on 4/04/26.

Official plan of correction

Board Director to pay the annual fee and submit proof by 4/29/26.

Deadline recorded: Apr 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87156(b)(1)(F)

Regulation authority

CCR

What the official deficiency says

87156 Licensing Fees: (b) (1) In addition to fees set forth in subdivision (a), the department shall charge the following fees: (F) A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing fee on or before the due date as... ....indicated by postmark on the payment. -This requirement is not met as evidenced by: -Based on review, the licensee did not pay the annual fee on or before the anniversary date which result to late fee charge.

Official plan of correction

Board Director to pay the late fee charge. Proof to be submitted by 4/29/26.

Deadline recorded: Apr 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports ...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ..(D) Any incident which threatens the welfare, safety or health of any resident... -This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section above in not submitting the incident reports for R1, R2 & R3 which posed a potential health and/or personal rights risks to persons in care

Official plan of correction

Administrator to do the following and submit proof by 7/30/25: 1. Submit incident reports. 2. Read the Regulations and self-certify timely submission of incident reports.

Deadline recorded: Jul 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.696(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in S1 has no 4 hours required training on file on postural support/restricted health conditions/hospice care which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2024 Plan of Correction Administrator to have the staff complete the training and submit proof by 5/31/24.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in S3 and S4 not First Aid certified which pose a potential health, safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2024 Plan of Correction Admiinistrator to have the staff register for training and submit copies of certificates by 5/31/24.

Official classification

Type B

Official code

87564(h)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in medication label of 1 of R5’s medication does not match the doctor’s order which poses a potential health and/or personal rights risks to person in care.

Official plan of correction

POC Due Date: 05/31/2024 Plan of Correction Administrator to obtain correct label and submit proof by 5/31/24.

Official classification

Type A

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (1) Nonambulatory persons. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation andvrecord review, the licensee did not comply with the section cited above in R2 being non-ambulatory and the facility has no fire clearance nor licensed for non-ambulatory which poses an immediate safety risk to person in care. A $500.00 civil penalty is assessed.

Official plan of correction

POC Due Date: 05/18/2024 Plan of Correction Administrator to issue an eviction and submit copy by 5/18/24.

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in not having carbon monoxide detectors in the West Wing and Azalea and Peralta Cottages which pose an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2024 Plan of Correction Administrator to have carbon monoxide detectors installed, and submit pictures by 5/02/24.

Official classification

Type A

Official code

87307(d)(7)

Regulation authority

CCR

What the official deficiency says

(7) Fireplaces and open-faced heaters shall be adequately screened. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in fire place in the living room not adequately screened which poses an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2024 Plan of Correction Administrator to have the fire place properly screened and locked, and send picture by 5/02/24.

Official classification

Type B

Official code

87303(f)(3)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in trash can in West Wing resident's bathroom without lid which poses a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 05/15/2024 Plan of Correction Administrator to purchase trash can with foot pedal operated lid, and submit picture by 5/15/24.

Official classification

Type B

Official code

87755(c)

Regulation authority

CCR

What the official deficiency says

87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying....... This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above in not having the disaster drill records not readily availabe for review which poses a potential safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 05/15/2024 Plan of Correction Administrator to submit copies of drill records for the last 3 quarters by 5/15/24.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section....... This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above in not having a certified administrator which poses a potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 05/15/2024 Plan of Correction Acting administrator stated she has completed the required training to renew her administrator certificate. Acting administrator to submit the following by 5/15/24: proof of completiion and payment for certification; job offer from licensee; signed letter from licensee requesting to expedite the processing of administrator certificate

Official classification

Type A

Official code

1569.17(b)(2)(E)

Regulation authority

HSC

What the official deficiency says

§1569.17 Fingerprints and criminal records of individuals in contact with clients...(b) (2)(E) Licensed or certified medical professionals are exempt from fingerprint and criminal background check requirements imposed by community care licensing. This exemption does not apply to a person who is a community care facility ...... ,,,,,,,licensee or an employee of the facility. -This requirement is not met as evidenced by; -Based on records review, the licensee did not comply with the section above for not having the staff fingerprint and associated. A civil penalty is assessed.

Official plan of correction

Administrator stated he'll have the staff fingerprinted. Proof to be submitted. by 08/25/2022. A $500.00 civil penalty is assessed.

Deadline recorded: Aug 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)

Regulation authority

HSC

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(15) To send and receive unopened correspondence in a prompt manner. -This requirement is not met as evidenced by: -Based on interview and observation, the licensee did not comply with the section above for R1's mail opened by staff and residents' mail left in the unlocked office which posed personal rights risks to persons in care.

Official plan of correction

Administrator to do the following:. 1. Come up with a plan to ensure the residents' mails are unopened and given in a timely manner. 2. In-service the staff. Proof to bve submitted by 9/07/2022.

Deadline recorded: Sep 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(3)

Regulation authority

CCR

What the official deficiency says

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(3) To confidential treatment of their records and personal information and to approve their release, except as authorized by law. -This requirement is not met as evidenced by: -Based on inspection, the licensee did not comply with the section above for residents' files kept in open shelves readily accessible to anyone.

Official plan of correction

Admiistrator stated he'll have the resident's files temporarily stored in the med room with lock until doors with lock are installed in the shelves. Picture to be submitted by 9/07/2022.

Deadline recorded: Sep 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Peritoneal cleanser was observed unlocked in a cabinet in one of the residents' toilets which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 04/07/2022 Plan of Correction Staff locked the item while LPA is at the facility, In addition, administrator to in-service the staff and submit proof by 4/07/2022.