Bethel Lutheran Home

Allegation investigated: Unqualified staff are administering insulin

On this date, Licensing Program Analyst (LPA) M. Yang conducted initial complaint investigation. LPA introduce self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Nursing Home Administrator Jasdeep Dhariwal who stated Administrator Benjamin Carter is unavailable to attend meeting. LPA discussed complaint and delivered complaint findings to Nursing Home Administrator. During the course of the investigation, the facility was toured, records were reviewed, and interviews were conducted. R1 and R2 are diabetes who has doctor’s order for insulin medications. Residents confirmed resident administers the residents’ own insulin injections. Based on interviews conducted, the allegation alleging unqualified staff are administering insulin, is found to be UNSUBSTANTIATED. Exit Interview was conducted. A copy of this report was provided to Nursing Home Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 25, 2025 · control 24-AS-20251124085118

Allegation investigated: Untrained staff providing care to residents

On this date, Licensing Program Analyst (LPA) M. Yang conducted initial complaint investigation. LPA introduce self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Nursing Home Administrator Jasdeep Dhariwal who stated Administrator Benjamin Carter is unavailable to attend meeting. LPA discussed complaint and delivered complaint findings to Nursing Home Administrator. During the course of the investigation, the facility was toured, records were reviewed, and interviews were conducted. All staff files providing care and supervision for residents, were reviewed and was observed to have no training records in the file. Nursing Home Administrator confirmed staff have no training records on file. Based on interviews conducted and records reviewed, the preponderance of evidences has been met. Therefore, the above allegation is found to be SUBSTANTIATED. An exit interview was conducted. A copy of this report and appeal rights were provided to Nursing Home Administrator whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Nov 25, 2025 · control 24-AS-20251124093651

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(2) · Plan of correction due date: Dec 5, 2025

87412 (c)(2) Documentation of staff training. This requirement is not met as evidenced by: Based on record review and interview conducted, the licensee did not comply with the section cited above when all staff files did not have the proper documentation and required trainings, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Licensee shall ensure that all staff have required trainings and continued trainings recorded. Licensee will submit a written statement detailing the steps the facility will take to ensure all staff training have the proper documentation including trainer’s full name, subject covered in the training, date of the training, number of hours of training per subject and have all required trainings on file. Written statement will be submitted to the Fresno CCL office by POC due date 12/05/25.

Type of visit: Case Management - Deficiencies

On 11/25/25, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced complaint investigation and met with Nursing Home Administrator Jasdeep Dhariwal who stated Administrator Benjamin Carter is unavailable to attend meeting. During the course of the investigation, LPA toured the facility, reviewed records, and conducted interviews. R1 and R2 are Diabetes with doctor’s order for insulin medication. R1 and R2 have no restricted health condition care plan for Diabetes health condition. R3 is receiving hospice care with no current hospice care plan on file. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Nov 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(b) · Plan of correction due date: Dec 5, 2025

87633(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident… This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when LPA reviewed R3’s file, whose currently receiving hospice care with no hospice care plan on file, which poses a potential health or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Administrator will obtain R3’s current hospice care plan and submit it to Fresno CCL by POC due date 12/05/25.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.39(b) · Plan of correction due date: Dec 8, 2025

1569.39(b) A residential care facility for the elderly that accepts or retains residents with restricted health conditions, as defined by the department, shall ensure that residents receive medical care as prescribed by the resident’s physician and contained in the resident’s service plan by appropriately skilled professionals acting within their scope of practice. An appropriately skilled professional may not be required when the resident is providing self-care, as defined by the department, and there is documentation in the resident’s service plan that the resident is capable of providing self-care. This requirement is not met as evidenced by: Based on record reviews, the licensee did not comply with the section cited above R1 and R1’s files were reviewed. R1 and R2’s who are diabetes with doctor’s order for insulin medication have no Restricted Health Condition care plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Administrator will obtain and submit a Restricted Health Condition care plan for R1 and R2. Restricted Health Condition care plan will be submitted to the Fresno CCL by POC due date 12/08/25.

Type of visit: Required - 1 Year

On 06/04/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit and met Administrator Kristine Williams and Licensed Vocational Nurse Kamal Singh. LPA toured facility with Administrator. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Fire extinguisher was observed throughout the facility with a service date of: 04/26/25. Last fire drill completed on 04/15/25. Fire sprinkler systems observed throughout the facility. Medications were observed locked in medication cart in medication room. MARs and medications were reviewed. A sample of residents’ bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured and observed operational during inspection. Hot water tested maintained at 109.2 degrees F in room 13, 105.2 degrees F in room 15, 107.2 degrees F in room 17, and 106.8 degrees F in room 23. Non-skid mat and grabbed bars were observed. An adequate supply of perishable and non-perishable food was observed. Adequate outdoor seatings available for residents and outside observed free of debris. Refrigerator temperature is maintained at 36 degrees F and freezer at -4 degrees F. Food delivery once a week and kitchen are shared with skill nursing facility. A sample of resident and staff files were reviewed. A deficiency and an immediate Civil Penalty was assessed. See Lic 421BG and Lic 421IM is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 06/10/25. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Theft and Loss Policies and Procedures, Administrator certificate, and current liability insurance. LPA copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Jun 4, 2025

Type of visit: Required - 1 Year

On 06/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. introduce self, stated the purpose of the visit and met Administrator Shikha Patterson and Licensed Vocational Nurse Teresa Gonzalez. LPA toured facility with Administrator. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Fire extinguisher was observed with a service date of: 03/08/24. All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured and observed operational during inspection. Non-skid mat and grabbed bars were observed. An adequate supply of perishable and non-perishable food was observed. Freezer temperature maintained at 0 degree F and refrigerator temperature maintained at 20 degrees F. Medications were observed locked in medication cart in medication room. MARs and medications were reviewed. Adequate outdoor seatings available for residents. A sample of resident and staff files were reviewed. Refrigerator temperature is maintained at 40 degrees F and freezer at 0 degrees F. Food delivery once a week and kitchen is shared with skill nursing facility. A deficiency and an immediate Civil Penalty of $500 was assessed. See Lic 421BG is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 06/24/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Administrator certificate, and current liability insurance. LPA copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Jun 17, 2024