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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700444
Report Date: 10/25/2021
Date Signed: 10/25/2021 03:43:47 PM

Document Has Been Signed on 10/25/2021 03:43 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:BETHEL ASSISTED LIVINGFACILITY NUMBER:
502700444
ADMINISTRATOR:VIVIANO, KIMBERLY MFACILITY TYPE:
740
ADDRESS:2325 & 2345 SCENIC DRTELEPHONE:
(209) 577-1901
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 125CENSUS: 102DATE:
10/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Kim Viviano, Executive Director (ED)TIME COMPLETED:
02:17 PM
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Licensing Program Analyst (LPA) Arlene Garcia arrived unannounced to conduct a case management visit. LPA met with Kim Viviano, Executive Director (ED) regarding purpose of today's visit.

LPA to follow up with Order to Bethel Assisted Community of Immediate Exclusion for former staff Lisa Marie Ramirez. No former staff at Bethel Assisted Community. Kim Viviano, Executive Director (ED) stated last day at facility for Lisa Marie Ramirez was 5/24/2021..

No deficiency cited during today's visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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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