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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700468
Report Date: 08/17/2021
Date Signed: 08/17/2021 02:45:54 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:KIND CARE HOMEFACILITY NUMBER:
502700468
ADMINISTRATOR:KAHLON, MANINDERDEEPFACILITY TYPE:
740
ADDRESS:1024 JAYHAWK WAYTELEPHONE:
(209) 523-0124
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY:6CENSUS: 0DATE:
08/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Maninderdeep KahlonTIME COMPLETED:
11:45 AM
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The facility has closed the property is being used as a CHLF/nursing care home licensed by the Department of Public Health. The facility has 2 residents in care at this time.

Licensee was made aware of the need to submit a letter of closure along with the original license to the department.

LPA also requested that the licensee complete the closure survey.

Exit interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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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