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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004527
Report Date: 10/29/2021
Date Signed: 10/29/2021 11:08:20 AM

Document Has Been Signed on 10/29/2021 11:08 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BETHANY ADULT DAY CAREFACILITY NUMBER:
397004527
ADMINISTRATOR:SMITH, SHANNONFACILITY TYPE:
775
ADDRESS:1010 WEST 2ND STREETTELEPHONE:
(209) 599-7670
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY: 12CENSUS: 0DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Heather BjerkeTIME COMPLETED:
11:45 AM
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On 10/29/21 at 10:33am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the assistant administrator Heather Bjerke and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, client room; resident bathrooms, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 12 bed adult day program with a current census of 0. Assistant Administrator stated facility has been closed due to COVID-19 since March of 2020. There is a dining area and a common area for clients. LPA also observed an activity area for clients. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs available. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed.

Water temperature reads 109.2*F in the bathroom and room temperature reads 69*F. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 4/21.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Assistant Administrator Heather Bjerke.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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