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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500300107
Report Date: 12/03/2021
Date Signed: 12/14/2021 01:34:16 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 MODESTOFACILITY NUMBER:
500300107
ADMINISTRATOR:JENNIFER BICEKFACILITY TYPE:
740
ADDRESS:1745 ELDENA WAYTELEPHONE:
(209) 529-4950
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:84CENSUS: 37DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Melina LewisTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced annual/random inspection on 12/03/2021. LPA met with Staff Melina Lewis and explained the purpose of the visit. Melina Lewis is the Administrator and holds a certificate# 6056092740 with an expiration date of 10/22/2023.

This facility is a single story building licensed to serve (84) non ambulatory residents at any given time. The facility has a hospice waiver up to (4) residents at any given time. LPA toured the physical plant including but not limited to two client bedrooms and bathrooms, and outside activity area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed the facility kitchen area to have 2 days of perishable food and 7 days of non perishable food. Hot water temperature was measured at (117) degrees Fahrenheit in hall bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguishers last serviced 08/03/2021. Thermostat observed at (76) degrees Fahrenheit. LPA observed toxins and sharp knives kept locked and inaccessible to residents. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.

The following forms need updating and were received during today’s visit on 12/03/2021:
LIC 308, LIC 500, LIC 610, certificate of liability insurance, resident roster, administrator certificate

There were no deficiencies found during today’s visit. Exit interview held with Melina Lewis and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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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