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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400043
Report Date: 05/19/2021
Date Signed: 06/22/2021 02:44:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BETHEL LUTHERAN HOME, INC.FACILITY NUMBER:
100400043
ADMINISTRATOR:PATTESON, SHIKHAFACILITY TYPE:
740
ADDRESS:2280 DOCKERY AVENUETELEPHONE:
(559) 896-4900
CITY:SELMASTATE: CAZIP CODE:
93662
CAPACITY:33CENSUS: 7DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Shika Patteson- AdministratorTIME COMPLETED:
12:20 PM
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On this date, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a required annual inspection. LPA met with Administrator Shika Patteson. LPA announced the purpose of the visit.

LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. The carbon monoxide and smoke detectors were functioning properly. The facility was adequately furnished and at a comfortable temperature. LPA toured resident bedrooms and bathrooms. Bedrooms were adequately furnished and lit. Bathrooms have required secure grab bars and nonskid mats. LPA and Administrator reviewed infection control guidelines and best practices.

No deficiencies were cited during the inspection. Exit interview was conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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