<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701370
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:15:00 PM

Document Has Been Signed on 03/05/2024 12:15 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BETHEL PLACE ASSISTED LIVING 2FACILITY NUMBER:
392701370
ADMINISTRATOR:NWAOGU, PRINCEWILLFACILITY TYPE:
740
ADDRESS:9738 NORTHSTAR CTTELEPHONE:
(925) 202-8447
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 0DATE:
03/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:NWAOGU, PRINCEWILTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/05/2024, Licensing Program Analyst (LPA) Kesha Lewis arrived announced to conduct a Pre-Licensing visit. LPA was greeted by applicants,NWAOGU, PRINCEWILL and explained the purpose of the visit. The purpose of this visit was to conduct a Pre-Licensing Visit.
This facility will be licensed to hold 6 residents, of which 4 may be non-ambulatory and 2 ambulatory.

A tour of the facility was conducted. Smoke detectors and carbon monoxide detectors were tested and are in good repair.

A tour of the kitchen area was done. A review of food supply was conducted to ensure a 2 day perishable and 7 day non-perishable food supply was available. This facility will have a locked medication cabinet located in the kitchen. A first aid kit was observed and had all the required components. Fire extinguisher was located in kitchen and was purchased on 10/30/2023.

A tour of the family room was conducted. Furniture and furnishings were observed to be in good repair.
A tour of the backyard was conducted with no hazards present. Perimeter gate was observed to be in good repair.
A tour of garage was conducted. A washer and dryer was identified. Detergent, toxins and other cleaning supplies were observed to be locked and made inaccessible.
A tour of the resident bedrooms were conducted. Furniture and furnishing were observed to meet the residents needs.
A linen closet was located in hallway and was observed to have a sufficient amount of linen to meet the residents needs at this time.
A tour of two resident restrooms were toured. Hot water temperature was taken to ensure that it was in within 105-120 degrees. Comp II was completed
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1