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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700113
Report Date: 11/08/2021
Date Signed: 12/02/2021 07:50:01 AM

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:CARING HANDS FOR THE ELDERLYFACILITY NUMBER:
502700113
ADMINISTRATOR:GUERRERO, ANAFACILITY TYPE:
740
ADDRESS:4229 GABRIEL WAYTELEPHONE:
(209) 604-1923
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 4DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Caregiver, Carmen ReynosaTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced to conduct the facilities annual inspection. LPA met with facility caregiver Carmen Reynosa and explained the purpose of todays visit. LPA observed a deceased resident being removed from the facility. The family of the resident was also present at the facility. LPA will conduct the annual inspection on a later date due to the circumstances.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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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