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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500300107
Report Date: 05/17/2024
Date Signed: 05/17/2024 02:40:20 PM


Document Has Been Signed on 05/17/2024 02:40 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: 49DATE:
05/17/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Stephany IssakhaniTIME COMPLETED:
03:00 PM
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On 5/17/2024 Community Care Licensing (CCL) had an meeting with the facility. Attending the meeting was Licensing Program Manager (LPM) Lisa Rios, and Licensing Program Analyst (LPA) Jason Lund. From the facility Assisted Living Director, Stephany Issakhani, and potential Licensee Rani Dhillon.

The facility gave a 60-day notice to Resident (R1) on April 17th, 2024. The facility will send a copy of R1’s admission agreement and wait from instructions from CCL to give a new 60-day notice. The facility will have board members email LPM Lisa Rios & LPA Lund proof the board is still running the facility until there has been a change of owner ship.


Exit interview conducted and report provided and emailed back to LPA Lund .
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024
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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