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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500300107
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:08:37 PM


Document Has Been Signed on 02/10/2023 03:08 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: DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:RCFE Director Stephany Issakhani TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jason arrived unannounced to conduct an annual/required inspection. LPA met with RCFE Director Stephany Issakhani and explained the purpose of the visit.

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 Lund & RCFE Director Stephany Issakhani 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 2/15/2022.

The following forms need updating and were received during today’s visit:
LIC 308, LIC 500, resume and certificate of liability insurance,

There were no deficiencies found during today’s visit. Exit interview held with RCFE Director Stephany Issakhani and a copy of report left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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