390312809-2-2-2024-27-AS-CYAG-D2444K-20240202174628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390312809
Report Date: 01/29/2024
Date Signed: 02/02/2024 05:46:46 PM

Document Has Been Signed on 02/02/2024 05:46 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 HAVEN		FACILITY NUMBER:	390312809
ADMINISTRATOR:	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:	01/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jose Ventura		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual 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. A tour of this facility was conducted alongside the facility designated Administrator Jose Ventura. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Jose Ventura. Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication rooms, located in each building, were reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were only private and semi-private living arrangements for residents on the Assisted Living portion of this facility. Hot water temperatures were taken and measured to make sure that they were within the allowed range of

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (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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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: 01/29/2024

NARRATIVE

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105-120 degrees.
Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
A tour of the Memory Care buildings, Building B and C, was conducted.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 05/05/2023 by the local fire extinguisher company, Cisco Fire Sprinklers Inc., and in compliance at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (7) facility resident files was conducted.
A review of (7) facility personnel files was conducted.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/02/2024 05:46 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87406(a)(1)(A)

Administrator Certification Requirements

(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. (1) Applicants who possess a valid Nursing Home Administrator license, issued by the California Department of Public Health, shall be exempt from completing an approved Initial Certification Training Program and taking a written exam, provided the individual completes twelve (12) hours of classroom instruction in the following Core of Knowledge areas: (A) Four (4) hours of instruction in laws, regulations, policies, and procedural standards that impact the operations of residential care facilities for the elderly, including but not limited to the authority referenced in this Chapter. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that [4] out of [7] facility staff training records did not meet the required number of update annual training hours which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/05/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all facility staff providing care and supervision to the residents will undergo, and receive, updated annual training to meet the required number of hours with certification on file for review. A statement of correction, along with training topics, name(s) of trainers, and list of attendees with course durations, will be completed and submitted into CCL by the due date of 02/05/2024.

Personnel Requirements - General

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/02/2024 05:46 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(c)1)

Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that facility staff did not have updated certified First Aid training on file which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/05/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all facility staff providing care and supervision to the residents will be trained and properly certified in First Aid at all times. A statement of correction, along with copies of updated First Aid training cards for the facility staff, will be completed and submitted into CCL by the due date of 02/05/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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