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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500300107
Report Date: 03/04/2022
Date Signed: 03/04/2022 02:36:51 PM


Document Has Been Signed on 03/04/2022 02:36 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
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: 32DATE:
03/04/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Okey OnyeaguchaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jason arrived at the above facility unannounced to conduct an annual/random inspection. LPA met with Administrator Okey Onyeagucha and explained the purpose of the visit. Administrator Okey Onyeagucha holds a certificate# 6053812740 with an expiration date of 10/6/2023.

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. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguishers last serviced 08/03/2021.

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

There were no deficiencies found during today’s visit. Exit interview held with and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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