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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701189
Report Date: 08/19/2022
Date Signed: 08/19/2022 09:16:21 AM

Document Has Been Signed on 08/19/2022 09:16 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BETHEL PLACE ASSISTED LIVINGFACILITY NUMBER:
392701189
ADMINISTRATOR:TALONGWA, CATHERINEFACILITY TYPE:
740
ADDRESS:9732 NORTHSTAR CT.TELEPHONE:
(209) 932-9481
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: DATE:
08/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Princewill Nwaogo, LicenseeTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) R. Campbell conducted an announced pre-licensing inspection and met with Princewill Nwaogo, LIcensee to confirm correction of issues. There were locks for drawers and cabinets in kitchen for sharps and cleaning supplies. Appropriate signage for complaints and ombudsman on walls and a PPE screening area. LPA observed 30 day supply of masks, sanitizer, glovews and gowns
Client rooms are equipped with the proper furniture and lighting. Client's rooms have proper bedding and linens for the client's to use. The kitchen was observed cleaned and within compliance. Bathrooms were equipped with grab bars. Living room is equipped with the proper furniture for the clients. Passageways and hallways are free of obstruction. Fire extinguisher is in compliance. Smoke detectors and Carbon Monoxide detector are equipped and functional around the facility.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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