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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700444
Report Date: 07/27/2022
Date Signed: 07/27/2022 02:47:09 PM


Document Has Been Signed on 07/27/2022 02:47 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 105DATE:
07/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Maria Castillo Padilla TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Arielle Pascua and Licensing Program Manager (LPM) Stephenie Doub arrived at this facility on 07/27/2022 at 12:15 pm to conduct an unannounced case management visit. LPA Pascua and LPM Doub met with Maria Castillo-Padilla and explained the purpose of today’s visit.

The purpose of today’s visit is to follow up on an incident report received on 07/21/2022. The report stated that on 07/17/2022 at 19:14, R1 became unresponsive during a bed tranfer. Staff called 911 and CPR was initiated while on the call with 911.

LPA Pascua and LPM Doub obtained R1's Physician report and facility records. Based upon interviews and facility records there were no deficiencies that were cited during this case management visit. LPA Pascua will come at a later time if further follow up is needed.

A copy of this report was provided to the facility and an exit interview was conducted.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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