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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390312809
Report Date: 03/04/2024
Date Signed: 05/14/2024 11:37:21 AM


Document Has Been Signed on 05/14/2024 11:37 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 HAVENFACILITY NUMBER:
390312809
ADMINISTRATOR:JOSE VENTURAFACILITY TYPE:
740
ADDRESS:368 S. WILMA AVE.TELEPHONE:
(209) 599-7670
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:59CENSUS: 43DATE:
03/04/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jose VenturaTIME COMPLETED:
12:00 PM
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A Noncompliance Conference (NCC) was conducted today on 03/01/2024, via Microsoft Teams. The purpose of the NCC was to discuss the Substantiated complaint of a violation of personal rights. Present at today’s NCC were the Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Charlie Yang, and facility designated Administrator, Jose Ventura, Kathy Lazernik (Facility Nurse), Cindy Scheublein (Executive Director) . The administrative process was explained during this meeting and the facility designated Administrator was informed that further citations may result in Administrative Action.

The focus of the concerns at this time:
  • Facility staffing
  • Personal Rights of the Residents
  • Personal Rights training and verification
  • Maintaining continued compliance
  • Oversight of facility staff for proper care and supervision
  • Reporting Requirements
  • Updating policies and procedures for resident fall risks


This facility and the facility designated Administrator agreed to the following:
  • Complete and submit the LIC 500 for the most current staff, shifts, and coverage for designated shift leads
  • Complete and submit the LIC 308
  • Complete and submit the LIC 309, as well as, the most updated documents from the Secretary of State filing for this corporation
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 03/04/2024
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  • Complete and submit proof of most recent training in the areas of Resident Personal Rights, Resident Care, and Resident Supervision. Proof of submission to include name of trainer, topics covered with duration of training, and list of all attendees
  • Complete and submit proof of most recent training for proper completion of the LIC 624 for all staff by 03/11/2024
  • Complete and submit proof of most recent training for fall prevention and updated policies and procedures for all staff by 03/11/2024

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
LIC809 (FAS) - (06/04)
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