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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701189
Report Date: 01/19/2023
Date Signed: 02/01/2023 03:54:05 PM

Document Has Been Signed on 02/01/2023 03:54 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
SACRAMENTO AC/SC, 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: 4DATE:
01/19/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Prince NwaoguTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kesha Lewis arrived to conduct an unannounced Post Licensing inspection on this date. Administrator certificate 6064213746 expires 10/16/2024.

LPA collected Certificate of Insurance for liability and reviewed the Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection.

LPA observed the following posted in the entrance of the facility: Resident Council Rights, See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Ombudsman Poster, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

Exit interview held with Administrator and a copy of report will be emailed as LPA'S printer is not working.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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