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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
500300107
Report Date:
02/26/2024
Date Signed:
02/26/2024 12:29:29 PM
Document Has Been Signed on
02/26/2024 12:29 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 SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
CASA DE MODESTO
FACILITY NUMBER:
500300107
ADMINISTRATOR:
STEPHANY ISSAKHANI
FACILITY TYPE:
740
ADDRESS:
1745 ELDENA WAY
TELEPHONE:
(209) 529-4950
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95350
CAPACITY:
84
CENSUS:
42
DATE:
02/26/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
11:15 AM
MET WITH:
HR Director Kristi Short
TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Jason arrived unannounced to conduct a case management visit. LPA met with
HR Director Kristi Short
and explained the purpose of the visit. Census:
Casa Da Modesto continues to meet quotas in the for staffing and the needs of the residents in care .
HR Director Kristi Short
will notify LPA Jason Lund of any changes or updates.
No deficiencies during today’s visit. Exit Interview and report left.
SUPERVISOR'S NAME:
Lisa Rios
TELEPHONE:
(916) 969-9685
LICENSING EVALUATOR NAME:
Jason Lund
TELEPHONE:
(916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE:
02/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/26/2024
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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