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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390312809
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:36:30 PM


Document Has Been Signed on 05/12/2022 12:36 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: DATE:
05/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Kathy LazernikTIME COMPLETED:
12:45 PM
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On 5/12/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management visit related to an incident report received on 4/20/22. LPA Jensen met with Administrator/ LVN Kathy Lazernik and explained the purpose of today's visit.

The incident report received on 4/20/22 was related to a resident's (R1) health condition which necessitated being sent to the hospital emergency department. LPA Jensen reviewed the file for R1, conducted an interview with Administrator Lazernik and conducted an in person interview with the spouse of R1. As a result of the case management investigation LPA Jensen determined that staff at the facility acted appropriately and sought medical attention for R1 in a timely manner.

Per California Code of Regulations Title 22, Division 6, no deficiencies were cited as a result of today's visit.

An exit interview was conducted and a copy of this report was given to Administrator Kathy Lazernik.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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