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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502700235
Report Date:
03/04/2024
Date Signed:
03/04/2024 03:23:19 PM
Document Has Been Signed on
03/04/2024 03:23 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
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
EL RIO MEMORY CARE COMMUNITY
FACILITY NUMBER:
502700235
ADMINISTRATOR:
KENT E MULKEY
FACILITY TYPE:
740
ADDRESS:
2828 HEALTHCARE WAY
TELEPHONE:
(209) 543-3805
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95356
CAPACITY:
72
CENSUS:
55
DATE:
03/04/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
02:45 PM
MET WITH:
Administrator Carlin Robertson
TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a case management visit regarding a incident reported to the department on 2/23/2024. LPA Lund was met by
Administrator Carlin Robertson
and explained the reason for the visit. Census:55
LPA Lund reviewed Resident (R1) Unusual Incident/Injury report dated 2/23/2024 which stated that R1 had a witnessed fall. The facility called hospice and then called 911. R1 was taken to the hospital from 2/23/2024 and returned on 2/25/2024. The facility is doing ½ checks on R1. The facility does have a fall plan in place for R1. R1 will continuing to have hospice which comes twice a week at this time. The facility has scheduled training on how to do proper changing procedures with residents in care.
No deficiencies were observed or cited at this time. Exit interview. Copy of report and appeal rights given.
SUPERVISOR'S NAME:
Lisa Rios
TELEPHONE:
(916) 969-9685
LICENSING EVALUATOR NAME:
Jason Lund
TELEPHONE:
(916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE:
03/04/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/04/2024
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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