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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390312809
Report Date: 10/29/2021
Date Signed: 10/29/2021 01:26:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BETH HAVENFACILITY NUMBER:
390312809
ADMINISTRATOR:SHANNON SMITHFACILITY TYPE:
740
ADDRESS:368 S. WILMA AVE.TELEPHONE:
(209) 599-7670
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:59CENSUS: 40DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Kathy Lazernik, AdministratorTIME COMPLETED:
01:35 PM
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On 10-29-21 at 11:23am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Kathy Lazernik and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside yard of the facility to ensure compliance with Title 22 regulations. Facility is a 59 bed assisted living facility with a current census of 40. Facility has a seperate memory care unit, a library area and formal dining room as well as a locked room for medication storage. Assisted living activities are conducted in the dining room and there is a separate break room for staff as well as a beauty salon. Memory care unit has a formal dining area and separate sitting area as well as a locked room for medication storage. Activities in memory care are conducted inside and outside facility as appropriate. There is a courtyard area leading out to a garden in memory care. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place.The facility has central entry point and has implemented screening and sign in procedures at the front door area with one designated entrance only at the assisted living section. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Assisted living water temperature reads 115.7*F in the bathrooms and room temperature reads 75*F. Memory care water temperature reads 115.5*F in the bathrooms and room temperature reads 73*F. LPA observed the facility to have adequate food supply in both memory care and assisted living.. Resident rooms were sanitary and had the required furniture and furnishings. {Cont. on 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BETH HAVEN
FACILITY NUMBER: 390312809
VISIT DATE: 10/29/2021
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The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 2/17/21 in both assisted living and memory care. Facility has an emergency food and water kit in both memory care and assisted living.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Kathy Lazernik
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
LIC809 (FAS) - (06/04)
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