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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004527
Report Date: 02/05/2025
Date Signed: 02/07/2025 09:41:20 AM

Document Has Been Signed on 02/07/2025 09:41 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BETHANY ADULT DAY CAREFACILITY NUMBER:
397004527
ADMINISTRATOR/
DIRECTOR:		VENTURA, JOSEFACILITY TYPE:
775
ADDRESS:1010 WEST 2ND STREETTELEPHONE:
(209) 599-7670
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY: 12CENSUS: 1DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jose Ventura and Heather BjerkeTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced Annual visit made out to this day program on 02/05/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff person, Heather Bjerke, who was briefly interviewed at this time.
The facility designated Administrator, Jose Ventura, arrived shortly thereafter to this day program while this LPA was conducting this visit.
Current census was 1 client who was currently at the nearby sister facility, Beth Haven, engaged in activities and meals at this time.
Tour of this day program was conducted.
Dining area, kitchen area, and all other areas designated for client use were observed to be furnished and maintained in compliance at this time.
All areas designated as classrooms, activity areas, and common areas for client use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the clients at this time.
Office rooms and other areas intended for client use were toured.
A review of the day program restrooms was conducted.
Hot water temperatures were taken to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees at all times.
Fire extinguisher, located in the kitchen area, was observed to have been annually inspected on 03/06/2024 by the local fire extinguisher company, Cisco Fire and Sprinkler Company, and in compliance at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were reviewed at this time.
The use of a microwave was observed to be present and in compliance at this time.
There was the presence of an oven and stove and were observed to be functional and in compliance at this time.
Facility food storage unit, refrigerator, was reviewed and observed to be functional and in good repair at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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: BETHANY ADULT DAY CARE
FACILITY NUMBER: 397004527
VISIT DATE: 02/05/2025
NARRATIVE
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Storage area for chemicals and cleaning supplies was observed to be locked and made inaccessible to the clients at this time.
Exterior grounds of this day program were toured at the rear area of this day program.
Facility perimeter fence, side gates, and all other exits were observed to be functional and in good repair at this time.

A file review was conducted for the day program client files (1) at this time. These details were noted on the following LIC 858.

A file review was conducted for the day program staff (2) files at this time. These details were noted on the following LIC 859.

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 left with the facility designated representative at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/07/2025 09:41 AM - It Cannot Be Edited


Created By: Charlie Yang On 02/05/2025 at 12:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BETHANY ADULT DAY CARE
FACILITY NUMBER: 397004527

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation from persons qualified by agencies including, but not limited to, the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that [2] out of [2] facility staff files did not contain updated First Aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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The facility designated representative stated that all day program staff will be scheduled, and complete, First Aid training. A statement of correction, along with copies of updated First Aid training, will be completed and submitted into CCL by the due date.
Type A
Section Cited
CCR
87466
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [1] facility client record was diagnosed with dementia and did not have an updated annual medical assessment completed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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The facility designated representative stated that all facility client files will be updated and completed to contain all required forms and documents at all times. A statement of correction, along with an updated annual medical assessment, will be completed and submitted into CCL by the due date.
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
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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