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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700438
Report Date: 09/06/2023
Date Signed: 09/06/2023 01:42:44 PM


Document Has Been Signed on 09/06/2023 01:42 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:ETERNITY CARE HOMEFACILITY NUMBER:
502700438
ADMINISTRATOR:PAYLA, MARIA ALONAFACILITY TYPE:
740
ADDRESS:1704 MOUNT VERNON DRTELEPHONE:
(209) 567-2812
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 4DATE:
09/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Maria PaylaTIME COMPLETED:
02:00 PM
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Licensee Program Analyst Jason Lund arrived unannounced to conduct an annual/required inspection. LPA Lund met Licensee/Administrator Maria Payla and explained the reason for the visit. Census 4. 6 non-ambulatory clients.

LPA Lund & Licensee/Administrator Maria Payla toured/inspected the facility including common areas, resident bathrooms, kitchen, dining room, laundry, storage, and outside yard area. The facility is clean and in good repair and no odors were detected. No hazards were noted in courtyard areas, hallways, doorways, etc. Fixtures and furniture all appear to be in good condition. Cleaning solutions are stored separately from food and locked. Handrails are present in all shower and toilet areas, are secured. Room temperature was 78 degrees. Medication was locked and secure. LPA Lund observed the fire extinguisher and carbon monoxide detector to be in compliance.

LPA Lund reviewed two staff & two resident files.

No deficiencies were observed at this time.

Exit interview conducted and report left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
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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