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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700444
Report Date: 04/16/2024
Date Signed: 04/18/2024 11:42:33 AM


Document Has Been Signed on 04/18/2024 11:42 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: 101DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Melissa OrelloTIME COMPLETED:
01:30 PM
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On 04/16/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Melissa Orello and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit.
This facility has two buildings which are licensed to serve and retain residents who are 60 and over. 2325 Scenic Dr is licensed to serve and retain 26 ambulatory residents, 49 bedridden residents. This building also has delay egress on the 2nd floor, and the 3rd floor may only have ambulatory residents only.
2345 Scenic Dr is licensed to serve and retain 50 bedridden residents on the 1st floor. 2nd and 3rd floor are are used for independent living only. This facility also has a hospice waiver for 34. This facility also has a dementia plan on file. This facility has also a new management company, Northstar Management, which was effective on 01/01/2024.

Current Census was 101. A brief interview with FDA Orello was conducted. A tour of the facility was conducted.

LPA requested and reviewed 4 resident files, and 10 staff files. The administrator has a current administrator certificate #60516330740 expires on 03/28/2025.

Due to insufficient time to conduct records review for resident files and conduct a tour of the facility, this LPA will return at a later date to continue the annual visit.
A technical assistance was provided for the following: 87411(c)(6)

No deficiencies or citations provided during the course of this visit.

An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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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