500300107-8-2-2021-27-AS-JLUD-C5HVKS-20210802163050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 500300107
Report Date: 08/02/2021
Date Signed: 08/02/2021 04:32:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	CASA DE MODESTO		FACILITY NUMBER:	500300107
ADMINISTRATOR:	JENNIFER BICEK		FACILITY TYPE:	740
ADDRESS:	1745 ELDENA WAY		TELEPHONE:	(209) 529-4950
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	84	CENSUS: 34	DATE:	08/02/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator Jennifer Bicek		TIME COMPLETED:	03:00 PM

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An office meeting was held in the Sacramento South RO via WebEx to discuss management changes and staffing concerns. Present at the meeting was Regional Manager (RM) Krystall Moore, RM of Sacramento North, Alycia Berryman, Licensing Program Manager (LPM) Stephenie Doub, Licensing Program Analyst (LPA) Jason Lund, ViJay Sharma, CFO Fellowship Homes, Amanda Clauson, Assistant Executive Director, Jennifer Bicek, Administrator, David Curtiss and Dale Tory, Peer Services Inc.

On July 30, 2021, the RO learned of staffing concerns at the facility. When following up on the concern, the RO also learned that the Licensee had entered into a management agreement with Peer Services Inc (PSI) on or around 7/15/2021. During the office meeting, the Licensee advised that PSI was acting as CEO once the previous CEO of Fellowship Homes recently resigned. The RO advised that the Licensee needed to complete an abbreviated application to add the management company. In regard to staffing, the AD stated that staff are working overtime to fill the staffing needs. She reported that staff are averaging about 120 hours worked per 80 hour work period. When staff are not able to work, management is then covering the shifts that need to be covered. The AD provided the normal staffing numbers but advised that with the low census and residents that do not have higher levels of care, the facility is able to meet needs if there is one staff does not show up to work. They can still cover the shift.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CASA DE MODESTO	FACILITY NUMBER: 500300107
	VISIT DATE: 08/02/2021

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In order for the facility to remain in compliance the licensee agreed to do the following:

· Submit documents for change of management by close of business 8/4/2021 to Centralized Applications Bureau

· Provided an updated LIC308 by 8/3/2021

· Staffing schedule to address leaving staff provided by 8/3/2021

· Updated LIC500 reflecting staffing changes

· Changes to staffing schedule will be provided within 24 hours when staff call out

· Designation of new administrator by close of business 8/6/2021

· Licensee to update Secretary of State filing

The licensee was reminded that PSI would not be able to act as the management company until approved by the Department.

The RO discussed mitigation measures for COVID. The AD advised that the facility conducts weekly testing of staff regardless of vaccination status. The facility has an adequate supply of PPE. Mitigation plan is in place.

An exit interview was conducted with AD Bicek and a copy of this report was provided.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021

LIC809 (FAS) - (06/04)

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