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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 251370262
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:15:06 PM

Document Has Been Signed on 08/23/2024 03:15 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MODOC WORK ACTIVITY CENTERFACILITY NUMBER:
251370262
ADMINISTRATOR/
DIRECTOR:		GLADU, ELIZABETHFACILITY TYPE:
775
ADDRESS:310 WEST C STTELEPHONE:
(530) 233-4527
CITY:ALTURASSTATE: CAZIP CODE:
96101
CAPACITY: 30CENSUS: 11DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Elizabeth Gladu Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 08/23/2024 at 12:30 PM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Executive Director Elizabeth Gladu and Program Coordinator Abigail Castellanos and explained the purpose of the visit.

LPA Benson and Executive Director toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to work area, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and client file review.



Common area was clean and in good repair. Kitchen was clean and in good repair. Work area was clean and in good repair. Cooking/dining equipment and utensils were present. Medication is locked in a locked closet.
First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients. All required postings are displayed within facility. The work area is clean and in good repair. The facility vehicles were inspected and are in good working order.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 04-19-24, the facility has been conducting drills every 6 months.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.



Exit interview conducted, a copy of the report, and appeal rights provided to Executive Director.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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Document Has Been Signed on 08/23/2024 03:15 PM - It Cannot Be Edited


Created By: Sarah Benson On 08/23/2024 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MODOC WORK ACTIVITY CENTER
FACILITY NUMBER: 251370262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82075(k)
Health-Related Services
(k) Medications shall be centrally stored under the following circumstances:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, inverview and record review, the licensee did not comply with the section cited above in that a client medication, aspirin 81mg was out dated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Staff disposed of medication in LPA's presents.
Staff will check for out dated medication monthly.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
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