502700493-9-25-2023-27-AS-KVIA-CVZLNA-20230925085359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700493
Report Date: 09/22/2023
Date Signed: 09/25/2023 08:54:10 AM

Document Has Been Signed on 09/25/2023 08:54 AM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GREENBACK MANOR		FACILITY NUMBER:	502700493
ADMINISTRATOR:	ABELLA, NICETAS		FACILITY TYPE:	735
ADDRESS:	1604 CARLISLE AVE		TELEPHONE:	(209) 567-2080
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 6		CENSUS: 6	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ma.Princes Mae Barcelona, Designee		TIME COMPLETED:	01:30 PM

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Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 09/22/23. LPA identified herself to the Caregiver on duty, explained the purpose of the visit, and asked to speak with Licensee/Administrator. Designee, per LIC 308 was called, Ma.Princes Mae Barcelona and she arrived shortly. LPA spoke with the licensee, Nicetas “Nessy” Abella, by phone and confirmed that Princess would be standing in for her today. A brief interview followed. Census at the time was 6 residents in care.

LPA noted the Administrator/Licensee, Nicetas Abella’s certificate, # 6002544735 expired on 5/22/23. Licensee provided proof of payment for renewal by email..

The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were dated appropriately.

LPA inspected the resident 5 bedrooms and 1 staff bedroom. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time.

LPA noted soap, paper towels and trashcans with lids in the bathrooms. The hot water temperature was measured at 110.4 degrees Fahrenheit and was in compliance. The 2 fire extinguishers were last serviced on 05/24/23 by Jorgensen Co. and were also in compliance.

The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. LPA observed that all screens and gutters were in good repair. There was 1 storage shed with a lock that contained yard equipment and storage items. There was also a covered patio area for residents to enjoy.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GREENBACK MANOR	FACILITY NUMBER: 502700493
	VISIT DATE: 09/22/2023

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The LPA observed medications were stored in a large locked metal cabinet in the kitchen and inaccessible to residents in care. Medications were primarily the pill packs provided by the pharmacy. LPA reviewed storage, dosing, and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance.

Emergency drill log was inspected and was up to date.

LPA completed a file review of 2 resident files and 2 staff files. All were in compliance. LPA reviewed a sampling of cash resources for 2 residents and at this time all funds were accounted for and records were in compliance.

According to the California Code of Regulations, Title 22, there were no deficiencies observed of cited during the visit.

A copy of this report was provided.

Exit interview.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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