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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500300107
Report Date: 11/28/2023
Date Signed: 11/28/2023 10:03:21 AM


Document Has Been Signed on 11/28/2023 10:03 AM - 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:CASA DE MODESTOFACILITY NUMBER:
500300107
ADMINISTRATOR:JENNIFER BICEKFACILITY TYPE:
740
ADDRESS:1745 ELDENA WAYTELEPHONE:
(209) 529-4950
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:84CENSUS: 49DATE:
11/28/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assisted Living Director, Stephany Issakhani TIME COMPLETED:
09:30 AM
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On 11/28/2023 Community Care Licensing (CCL) had an office meeting with the facility. Attending the meeting was with Regional Manager (RM) Stephenie Doub, Licensing Program Manager Lisa Rios, and Licensing Program Analyst (LPA) Jason Lund. From the facility Assisted Living Director, Stephany Issakhani and (Board chair & accounts payable) Nannette McKay.

The facility wanted to notify CCL that they were able to make payroll for December 5th. The facility notified CCL that the skilled nursing had 8. The facility also notified that currently residents in care have not been affected by the situation. The facility has asked to have a weekly meeting with CCL.


Exit interview conducted and report provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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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