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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500300107
Report Date: 08/01/2021
Date Signed: 08/01/2021 01:59:42 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:
08/01/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:GabeTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check. LPA followed up on requested information with Amanda and Jennifer via text message.

LPA confirmed that staffing is sufficient today and there are no unmet needs for the residents in care. The facility is staffed to provide no gaps between shifts; this includes staff working doubles and/ or coming in on their days off to continue to meet the staffing needs.

The department has scheduled a telephone meeting at 2pm on 8/2/2021 and has requested that Gary from Casa to be on the call tomorrow in conjunction with David from Peer Services.

Health and Safety check has concluded for today. The overall safety of the facility including food supply, physical plant and staffing.

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: 08/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2021
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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