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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700444
Report Date: 03/13/2024
Date Signed: 03/25/2024 09:00:39 AM


Document Has Been Signed on 03/25/2024 09:00 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:BETHEL ASSISTED LIVINGFACILITY NUMBER:
502700444
ADMINISTRATOR:MITCHAEL WORDFACILITY TYPE:
740
ADDRESS:2325 & 2345 SCENIC DRTELEPHONE:
(209) 577-1901
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:125CENSUS: 112DATE:
03/13/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mitchael WordTIME COMPLETED:
12:00 PM
NARRATIVE
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An informal conference was conducted on this day, 03/13/2024 via Microsoft Teams. The purpose of the informal conference was to discuss the facilities complaince with Title 22 Regulations. Present at today's meeting were Licensing Program Manager (LPM), Lisa Rios and Licensing Program Analyst (LPA), Arielle Pascua, Licensee, Mitchael Word, Northstar Management Company Representative, Jessica Quintana, and Facility Designated Administrator (FDA), Melissa Orellos.

The following issues were discussed during the informal conference:
· Sufficient Staffing including confirmation of current staffing agency contracts, Assisted Living staffing and Memory Care staffing
· Food supply
· Medications

Licensees stated they will do the following to achieve continued and substantial compliance:
  • Provide LPA Pascua a copy of food supply puchased within the last 6 months.
  • Ensure that is sufficient staff on site to meet the residents needs
  • Have hydration stations and extra snacks provided to the residents throughout the day
  • Have a back up system to call staff in when staff on schedule call out on shift.

Licensing will:
Increase monitoring to verify:
  • Internal Audits of Medications is being completed by the facility
  • Staffing are sufficient to meet the needs of the residents
  • Food supply is sufficient to meet resident needs.
No deficiencies were cited from the California Code of Regulations, Title 22, Division 6 as a result of today's meeting. An exit interview was conducted and a facility report was provided via email read receipt.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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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