Bethany Joy Garden

Allegation investigated: Staff did not safeguard residents personal belongings

On 06/04/2026, Licensing Program Analysts (LPAs) M. Medina and J. Duarre conducted a subsequent unannounced complaint visit to deliver findings. LPAs introduced self, stated purpose of visit, and allowed entrance by direct care staff. Lilibeth Estomata, Licensee contacted by telephone and was unavailable to conduct today's complaint visit. LPAs delivered findings via telephone to licensee and the report was signed by staff on shift. . This department investigated the above allegations during the investigation, LPAs toured facility and conducted interviews. This department had insufficient information regarding the allegation listed above. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove or disprove that the allegation occurred therefore the allegation is UNSUBSTANTIATED. No deficiencies issued during this complaint visit.. Exit interview conducted. A copy of this report was provided to Licensee for facility records Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 4, 2026 · control 24-AS-20260513125529

Allegation investigated: Staff did not accept resident back from hospital

On 5/18/2026, Licensing Program Analyst (LPA) M. Medina arrived to conduct an unannounced initial 10-day complaint visit. LPA arrived, introduced self, stated purpose of visit, and allowed entrance to facility by staff. Licensee was not available to conduct today's complaint visit, LPA spoke with Licensee via telephone to advise of complaint and conduct interview. During the course of the investigation, interviews were conducted. Based on information gathered during interviews, R1 was ready for discharge from hospital on 5/15/2026 and was not accepted back at facility. Per licensee, they can no longer meet resident's needs. The preponderance of evidence standard has been met, therefore the above allegation of is found to be SUBSTANTIATED. A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 9099D. Exit interview was conducted and a plan of correction developed and reviewed. A copy of this report provided to staff for facility records. . Substantiatedthe state’s words, verbatim · CDSS document, May 18, 2026 · control 24-AS-20260517122302

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: May 25, 2026

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) **This was not met as evidenced by: R1 was ready for discharge from hospital on 5/15/2026 and was not accepted back at facility. Per licensee, they can no longer meet resident's needsthe state’s words, verbatim · CDSS document, May 18, 2026

Plan of correction: Licensee will read regulation section 87224 and submit written statement acknowledging they have been read and understand was is stated. POC to be submitted to Fresno Regional Office by due date.

Type of visit: Case Management - Other

On 5/22/2026, Licensing Program Analyst (LPA) M, Medina conducted a Case Management visit due to interviews conducted during complaint (#24-AS-20260517122302) visit on this date. During interviews conducted, it was reported by licensee that there had been numerous incidents with resident 1 (R1) prior to hospitalization that had not been reported to department as required by Title 22 regulation. LPA advised Licensee via telephone of case management report. A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 9099D. Exit interview conducted via telephone with licensee and a plan of correction was developed and reviewed. A copy of this report provided to facility via email for facility records. .the state’s words, verbatim · CDSS document, May 18, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 25, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. **This was not met as evidenced by: During interview licensee it was reported by licensee that there had by numerous incidents with resident that had not been reported to department as required by Title 22.the state’s words, verbatim · CDSS document, May 18, 2026

Plan of correction: Licensee will submit all incident reports for incidents that have occurred to department. Licensee will read regulation section 87211 and submit written statement acknowledging they have read and understand was is stated. POC to be submitted to Fresno Regional Office by due date.

Allegation investigated: Facility did not provide supervision allowing resident to walk the neighborhood freely

On 4/22/2026, Licensing Program Analyst (LPA) M. Medina arrived to conduct an unannounced initial 10-day complaint visit. LPA arrived, introduced self, stated purpose of visit, and allowed entrance to facility by staff. Licensee was not available to conduct today's complaint visit, LPA met with staff to conduct visit. During the course of the investigation, documents were reviewed, interviews conducted and observations made. Based on information gathered during interviews, and review of video surveillance, R1 left facility unassisted by staff. The preponderance of evidence standard has been met, therefore the above allegation of is found to be SUBSTANTIATED. A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 9099D. An immediate Civil Penalty is being Assessed on the attached LIC421M Exit interview was conducted and a plan of correction developed and reviewed. A copy of this report provided to staff for facility records. . Substantiatedthe state’s words, verbatim · CDSS document, Apr 22, 2026 · control 24-AS-20260415154451

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 23, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ***This was not met as evidenced by review of video surveillance, R1 left facility unassisted by staff. IMMEDIATE CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Licensee to submit a written plan to department to ensure how regulation will be met.

Type of visit: Required - 1 Year

On 11/24/2025, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self, stated purpose of visit and allowed entrance into facility by Direct Care Staff. Licensee, Lilibeth Estomata contacted by telephone and was not available to conduct today's inspection visit. LPA conducted facility tour with direct care staff. Currently, three (3) residents in care. Residents were all present during today's inspection. Residents were observed to be relaxing in the family room and resting in their bedroom All common area observed to have adequate seating and lighting available. Resident bedrooms toured, all bedrooms observed to have required furnishings. Linens observed to be clean and in good repair. Resident bathrooms toured, fixtures observed to be clean and operational during inspection. Showers observed to have grab bars, skid-resistant mats, and shower chairs available. Water temperature measured at 109 degrees F. Kitchen tour conducted, sharps and knives are stored and secured in kitchen cabinet. Medications observed to also be locked and secured in cabinet. All cleaning supplies are locked and secured and inaccessible to residents. Fire extinguisher present with a service date of 1/14/2025. Outside of the facility toured, all exits open free of obstruction. Facility has outdoor seating and shade available for residents. Due to time constraints LPA will return to review medication, staff and resident files and complete inspection tool. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Nov 24, 2025

Type of visit: Required - 1 Year

On 11/07/2024, Licensing Program Analyst (LPA) M Medina conduced an unannounced Annual Required inspection. LPA arrived, introduced self, stated purpose of visit and allowed entrance by Direct Care Staff. Licensee/Administrator contacted by telephone and was not available to conduct facility inspection. LPA conducted facility tour with Gemma Jones, Lead Care Staff. Currently, there are six (6) residents in care. All were present at time of inspection. LPA observed facility to be clean, odor free, and a comfortable temperature. Facility is 4 bedrooms and 2 bathroom, there are 2 shared room and 2 private bedrooms. Facility tour conducted with Lead Care Staff. All common areas have adequate seating available for all residents in care. Kitchen toured, LPA observed facility to have a 2-day supply of perishable and a 7-day of non-perishable food available. LPA observed all food to be properly stored and dated. LPA observed stove knobs to be removed and secured. All knives and sharps were also observed to be locked and secured. All resident bedrooms toured, bedrooms observed to have all required accommodations available. Resident bathrooms toured. LPA observed fixtures to be operational during inspection. LPA observed grab bars, non-skid mats, and grab bars in the shower/tub areas, as well as near toilets. Water temperature measured at 116 degrees F. Medications observed to be locked and secured. LPA observed medications to have original labels and to be administered as prescribed. Cleaning supplies observed to be locked and secured in cabinets in garage, as well as in laundry room which is locked and secured. Fire extinguishers present with a service date of 11/27/2023. Carbon monoxide detectors and smoke detectors observed operational at time of inspection. Outside of facility toured. All exits open free of obstruction. No hazards observed. Resident and staff files reviewed. A copy of this signed report will be provided to Licensee via e-mail for their records. No deficiencies cited.the state’s words, verbatim · CDSS document, Nov 7, 2024

Type of visit: Required - 1 Year

On 11/27/2023, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA introduced self, stated purpose of visit and allowed entrance by direct care staff. Licensee/Administrator, Lilibeth Estomata contacted by telephone and arrived a short time later to conduct inspection. Facility tour conducted with Licensee. Facility tour began in resident bedrooms. Rooms observed to be sufficiently furnished with adequate lighting. Residents bathrooms observed to be clean and in good repair. Bath/tub are have non-skid mats and grab bars. Hot water tested in both bathrooms with a water temperature of 119 degrees F. Dining room and living room have adequate seating and lighting for all residents in care. Tour of kitchen conducted. LPA observed a two day supply of perishable food and a seven day supply of nonperishable food available. All foods and leftovers stored in the refrigerator and/or freezer observed to be properly stored and labeled. All medications observed to be locked and secured in kitchen cabinet . Medication observed to have all original labels and to be administered as prescribed. All sharps are locked and secured and inaccessible to residents. All cleaning supplies are locked and secured in cabinet. Last fire drill conducted on 11/03/23 according to facility records. Outside of facility toured. Seating is available for residents, all exits observed to be free of obstruction. Staff and resident files reviewed. No deficiencies observed. Exit interview was conducted, facility report signed and a copy provided for facility records.the state’s words, verbatim · CDSS document, Nov 27, 2023