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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390312809
Report Date: 01/29/2024
Date Signed: 02/02/2024 05:47:19 PM


Document Has Been Signed on 02/02/2024 05:47 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
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:
01/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jose VenturaTIME COMPLETED:
02:30 PM
NARRATIVE
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Unannounced case management visit made out to this facility on 01/29/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Jose Ventura, who was briefly interviewed. It was learned that there were residents under the care of hospice at this time while other residents were receiving services through home health as well.
This facility does have a hospice waiver approved for (5) residents and program on file for dementia care unto the residents at any given time.
Current census was 43 residents, of which, 27 were in the Assisted Living building (Building A). The other 16 residents, of which (8) were living in Building B and another (8) in Building C were considered as Memory Care.
The purpose of this case management visit was to discuss the recent submission of Special Incident Reports (SIR) into CCL that were reviewed by this LPA.
This discussion was held with the facility designated Administrator Jose Ventura at this time.
It was learned that policies and procedures were put into place to address the issues from the SIRs. It was learned that certain staff were re-trained while other staff were subject to disciplinarian action after an investigation was completed.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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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