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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500300107
Report Date: 03/11/2024
Date Signed: 03/11/2024 02:33:20 PM


Document Has Been Signed on 03/11/2024 02:33 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 MODESTOFACILITY NUMBER:
500300107
ADMINISTRATOR:STEPHANY ISSAKHANIFACILITY TYPE:
740
ADDRESS:1745 ELDENA WAYTELEPHONE:
(209) 529-4950
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:84CENSUS: 48DATE:
03/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:RCFE Director Stephany IssakhaniTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jason arrived unannounced to conduct a case management visit. LPA met with RCFE Director Stephany Issakhani and explained the purpose of the visit. Census: 40

Casa Da Modesto was recently sold on February 28, 2024. The facility notified LPA Lund of the sale of the facility. The facility has given 60- day notice to residents and POA of residents in care. The facility will get with Department of Socials Services to get a new license. RCFE Director Stephany Issakhani 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 RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
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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