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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500300107
Report Date: 12/19/2023
Date Signed: 01/23/2024 09:14:25 AM


Document Has Been Signed on 01/23/2024 09:14 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:
12/19/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assisted Living Director, Stephany IssakhaniTIME COMPLETED:
09:30 AM
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On 12/19/2023 Community Care Licensing (CCL) had an office meeting with the facility. Attending the meeting was Licensing Program Manager Lisa Rios, and Licensing Program Analyst (LPA) Jason Lund. From the facility Assisted Living Director, Stephany Issakhani, and Human resources Kristi Short.

The facility wanted to notify CCL that they were able to make payroll for December 19th. The facility notified CCL that the skilled nursing has no residents in care. The facility also notified that currently residents in care have not been affected by the situation. The facility will be remodeling the facility and getting with fire department for approval for updates.


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: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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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