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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700415
Report Date: 08/12/2021
Date Signed: 08/12/2021 05:28:35 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:DIGNICARE LIVING LLCFACILITY NUMBER:
502700415
ADMINISTRATOR:EVANGELIO, JR, NAPOLEONFACILITY TYPE:
740
ADDRESS:3100 DOVEHOUSE LNTELEPHONE:
(209) 551-0787
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 5DATE:
08/12/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Marissa Raisas, CaregiverTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced case management visit on 08/03/2021 to amend a citation and to clear deficiencies associated with Annual Infection Control Visit on 8/6/2021 . LPA identified herself and discussed the purpose of the case management visit with Marissa Raisas, Caregiver.

LPA observed Carbon Monoxide has been installed in main living area.

LPA observed Toxins locked and training for staff completed.

As a result of the file review, it was determined citations were revised under the RCFE Regulations. LPA Garcia went over the citation revision with Marissa Raisas, Caregiver, and an exit interview was conducted. In addition, a copy of this report was given to Marissa Raisas, Caregiver.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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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