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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390312809
Report Date: 03/09/2022
Date Signed: 03/09/2022 12:32:01 PM


Document Has Been Signed on 03/09/2022 12:32 PM - It Cannot Be Edited

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: 35DATE:
03/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kathy Lazernik - Interim AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Case Management Incident visit. LPA met with Interim Administrator and discussed purpose of visit.

LPA reviewed incident report and discussed with Interim Administrator the occurrence regarding resident(1) to resident (2's) physical altercation on December 21, 2021.. See LIC 811 for Confidential Names. LPA reviewed current R1's and R2's current LIC 602 Physician's Reports, and resident care notes.

R1 was moved to another memory care house on December 21, 2021 and no other incidents have occurred.

No deficiencies cited on today's visit.

Exit interview conducted with Interim Administrator and copies of reports left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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