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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701370
Report Date: 07/23/2024
Date Signed: 07/23/2024 10:49:39 PM

Document Has Been Signed on 07/23/2024 10:49 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/
DIRECTOR:
NWAOGU, PRINCEWILLFACILITY TYPE:
740
ADDRESS:9738 NORTHSTAR CTTELEPHONE:
(925) 202-8447
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 3DATE:
07/23/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:NWAOGU, PRINCEWILLTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 7/23/24, Licensing Program Analyst (LPA) Kesha Lewis arrived at this facility unannounced to conduct a post-licensing inspection. LPA met with Administrator and explained the purpose of the visit. Administrator assisted LPA with today’s inspection.

Administrator’s certificate is current and will expire on 10/24. This facility is three licensed for 2 ambulatory and 2 non-ambulatory client and hospice waiver for 3. Current census is 3. There were one direct care staff on duty during today’s visit.

LPA toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed the kitchen, bedrooms, bathrooms, medication, laundry area and common areas. LPA observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature was measured at 107*F which was within the required range of 105-120*F. The temperature inside the facility was observed to be at 75*F which was within the required range of 68-85*F.

LPA observed the centrally stored medication areas to be locked and made inaccessible to the clients at this time. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair.

LPA reviewed staff and resident files.


An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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