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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200320
Report Date: 08/11/2023
Date Signed: 08/11/2023 05:10:41 PM


Document Has Been Signed on 08/11/2023 05:10 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BETHEL CARE HOME ON COTTAGEFACILITY NUMBER:
079200320
ADMINISTRATOR:CARLA BLAJFACILITY TYPE:
740
ADDRESS:36 COTTAGE LANETELEPHONE:
(925) 280-6000
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
08/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:CARLA BLAJTIME COMPLETED:
05:00 PM
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On 08/11/2023 at 8:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived at facility for Required Annual Inspection. Upon arrival, LPA stated purpose of the inspection to Administrator (ADM) CARLA BLAJ.

LPA and ADM toured facility inside and outside. Facility is clean and safe and well maintained. LPA reviewed files of 5 residents and 4 staff members and found them to be accurate and up-to-date. LPA interviewed 2 staff and 2 residents, and found the staff to be fully competent and the residents to be well cared for.

No citations issued during the inspection.

Exit interview conducted with ADM. A copy of this report provided for ADM by LPA via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
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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