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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500300107
Report Date: 07/31/2021
Date Signed: 07/31/2021 03:43:40 PM

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:CASA DE MODESTOFACILITY NUMBER:
500300107
ADMINISTRATOR:JENNIFER BICEKFACILITY TYPE:
740
ADDRESS:1745 ELDENA WAYTELEPHONE:
(209) 529-4950
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:84CENSUS: 37DATE:
07/31/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Gabe and TessTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check. LPA also followed up on requested information with Jennifer and Amanda.

Health and Safety check included overall safety of the facility including food supply, physical plant and staffing.


The facility will provide the department with the requested information by 8/1/2021. The information requested includes:

LIC 500, copy of liability insurance and copy of management agreement with PEER Management. LPA Johnson has a copy of the July 31st and August 2021 work staff schedule.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.


Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2021
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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