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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700444
Report Date: 12/05/2023
Date Signed: 12/06/2023 09:04:20 AM


Document Has Been Signed on 12/06/2023 09:04 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: 110DATE:
12/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mitch WordTIME COMPLETED:
02:30 PM
NARRATIVE
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On 12/05/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Administrator, Mitch Word and Facility Designated Representative (FDR), Jim Sidoti and explained the purpose of the visit.

The purpose of this visit was in response to the complaint visit to this facility that was conducted on 12/05/2023. It was learned during this visit that S1 was currently not associated to the facility roster.

LPA reviewed the Licensing Information System (LIS) and Guardian portal to determine of S1 was associated at this time. It was observed that S1 was not associated to this facility as of this date.

An immediate civil penalty of $500 was issued at the time of this visit due to violation of Section 87355(e)(2).

Based on the information gathered during the course of this visit, per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, and a copy of the report will be given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/06/2023 09:04 AM - 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: BETHEL ASSISTED LIVING
FACILITY NUMBER: 502700444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2023
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This is not met as evidenced by:
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Licensee shall provide a statement of acknowledge and correction of the mentioned Section. Licensee shall ensure that S1 is associated to the facility by POC date.
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Based on record review and observation, the Licensee did not ensure that S1 was currently associated to this facility as of 12/05/2023.
LPA reviewed both LIS and Guardian and did not observed S1 currently associated to the facility at this time. This poses an immediate health, safety, and personal rights risks to persons in care.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
LIC809 (FAS) - (06/04)
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