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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
390312809
Report Date:
09/23/2024
Date Signed:
09/24/2024 08:52:23 AM
Document Has Been Signed on
09/24/2024 08:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
BETH HAVEN
FACILITY NUMBER:
390312809
ADMINISTRATOR/
DIRECTOR:
JOSE VENTURA
FACILITY TYPE:
740
ADDRESS:
368 S. WILMA AVE.
TELEPHONE:
(209) 599-7670
CITY:
RIPON
STATE:
CA
ZIP CODE:
95366
CAPACITY:
59
CENSUS:
43
DATE:
09/23/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:
Jose Ventura
TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Unannounced case management visit conducted on 09/23/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Jose Ventura.
Current census was 37 residents.
The purpose of this case management visit was to follow up and inquire about recent incident reports in regards to facility residents and their related care.
An interview was conducted with the facility designated Administrator Jose Ventura in regards to these incident reports involving R1 and R2 at this time.
There were no deficiencies observed or cited during today's case management visit.
Exit Interview
SUPERVISORS NAME
:
Liza King
LICENSING EVALUATOR NAME
:
Charlie Yang
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/23/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/23/2024
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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