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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700438
Report Date: 09/05/2024
Date Signed: 09/05/2024 09:27:49 PM


Document Has Been Signed on 09/05/2024 09:27 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: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: 5DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Maria PaylaTIME COMPLETED:
03:30 PM
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Licensee Program Analyst Jason Lund arrived unannounced to conduct an annual/required inspection. LPA Lund met Administrator Maria Payla and explained the reason for the visit. Census 5.

LPA 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 in areas toured. No hazards were noted in courtyard areas, hallways, doorways, etc. No equipment was stored in public areas. Fixtures and furniture all appear to be in good condition. Cleaning solutions are stored separate from food. Handrails are present in all shower and toilet areas, are secured. Room temperature was comfortable in facility. There are no bodies of water on the premises.

Facility has supply of bedding and towels. Furniture is appropriate in bedrooms for residents. There is adequate closet/drawer space available. There are plenty of bathrooms for number of residents. Non-skid mats will be purchased for the two showers. Emergency lighting available. Kitchen appears to be clean, well-supplied with equipment. Cooler/freezer appear to be at appropriate temperatures. First aid supplies available in several locations. Laundry equipment present, working telephone, emergency lighting. Medication was locked and secure. LPA Lund observed the fire extinguisher (08/21/2024) 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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