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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390312809
Report Date: 01/13/2023
Date Signed: 01/13/2023 01:42:08 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/13/2023 01:42 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:BETH HAVENFACILITY NUMBER:
390312809
ADMINISTRATOR:SHANNON SMITHFACILITY TYPE:
740
ADDRESS:368 S. WILMA AVE.TELEPHONE:
(209) 599-7670
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY: 59CENSUS: 34DATE:
01/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jose VenturaTIME COMPLETED:
01:45 PM
NARRATIVE
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On 1/13/23 at 10:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Administrator Jose Ventura and explained the purpose of today's visit. Administrator Jose Ventura holds a current Administrator's certificate # 6040548740.

The facility consists of 3 single story buildings, 1 building is utilized for assisted living and 2 buildings are for memory care. The memory care buildings are gated. The grounds were observed to be well maintained and there are no bodies of water on the property.

LPA Jensen toured all 3 buildings including resident rooms, kitchens,common areas, medication rooms, laundry room, hair salon, library and dining room. The facility was observed to be well lit, sanitary and free of odor. The facility was adequately furnished for the comfort of residents in care. The temperature in facility ranged from 70 degrees to 76 degrees which falls within the regulatory range of 105 - 120 degrees. The water temperature was measured in resident and in the kitchenette in the memory care buildings and ranged between 116 - 117 degrees which falls within the required range of 105 degrees to 120 degrees. The bathrooms were observed to be equipped with grab bars at the toilet and in the shower. The shower was observed to have non-slip flooring. the facility maintains an adequate supply of linens and bedding. The hallways were observed to be equipped with night lights and the resident rooms were equipped with night lights as well. The air filters were in good condition and all vents were observed to be free of dust and debris.

The carbon monoxide detectors and fire alarms were tested and observed to be in good working order. They are combined units with a ten year battery that was installed in 2021. The fire extinguishers were last served in May of 2022 and are in compliance. The Ansul system was last serviced in November of 2022 and is in compliance. The facility maintains a first aid kit and supplies complete with a manual, scissors, tweezers and thermometer. The facility maintains a 30 day supply of PPE and conducts COVID screening and temperature checks upon entry.
Continued on LIC 809C...



SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BETH HAVEN
FACILITY NUMBER: 390312809
VISIT DATE: 01/13/2023
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LPA Jensen observed signs posted including but not limited to Long Term Care Ombudsman, Say Something See Something, Resident Rights, Resident Council and COVID infection precautions. An oversized activity calendar is posted with a variety of activities available for residents in care including but not limited to worship services, bingo, hot chocolate bar, outings to cafes, trivia games and shopping excursions.

The Medication room was observed to be locked and inaccessible to residents in care. Narcotics were observed to be double locked in the medication room. LPA Jensen did a narcotic count for resident 1 (R1) in the presence of the Administrator and staff nurse and determined the facility records were accurate. LPA Jensen verified that the effectiveness of PRN medication is being documented.

All sharp objects in all 3 buildings were observed to be locked and inaccessible to residents in care. LPA Jensen observed chemicals in the the memory care building B to be unlocked in the kitchenette under the sink. LPA Jensen also observed chemical in a cleaning supply room to be unlocked in the memory care building C. At the time of LPA Jensen's visit chemicals/cleaning supplies were accessible to residents in care in both memory care buildings. Upon bringing this matter to the attention of the Administrator the chemicals were locked and made inaccessible.

LPA Jensen requested the following records to be emailed to maja.jensen@dss.ca.gov by 1/20/23:

An updated LIC 500
Current Liability Insurance Certificate

Deficiencies are being cited from the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/13/2023 01:42 PM - It Cannot Be Edited


Created By: Maja Jensen On 01/13/2023 at 01:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BETH HAVEN
FACILITY NUMBER: 390312809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2023
Section Cited
CCR
87705(f)(2)

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Care of Persons with Dementia
The following shall be stored inaccessible to residents with dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by:
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The Licensee immediately locked all cleaning supplies and will conduct an inservice training with staff within one week. The Licensee will email verification that the inservice training has been completed to maja.jensen@dss.ca.gov by 1/20/23
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Based on LPA Jensen's observation of cleaning supplies accessible in both memory care buildings. This poses an immediate risk to teh health, safety and personal rights of residents 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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


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