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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004527
Report Date: 02/22/2024
Date Signed: 02/22/2024 04:39:41 PM

Document Has Been Signed on 02/22/2024 04:39 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: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:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nurse Kathy Lazernik TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived the facility unannounced to conduct an annual/required visit. LPA met with Nurse Kathy Lazernik and explained the purpose of the visit.

LPA Lund & Nurse Kathy Lazernik toured/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. Nurse Kathy Lazernik stated that they have residents three days a week. There is a dining area and a common area for clients. LPA also observed an activity area for residents. Water temperature in the bathroom was within the range of 105*F and 120*F and room temperature was within 68*F and 85*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 5/5/2023. LPA Lund reviewed two staff & two residents files.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Nurse Kathy Lazernik and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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