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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700517
Report Date: 09/13/2021
Date Signed: 09/29/2021 08:24:27 AM

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 HOME IIFACILITY NUMBER:
502700517
ADMINISTRATOR:KAHLON, HARDEEPFACILITY TYPE:
740
ADDRESS:1020 JAYHAWK WAYTELEPHONE:
(209) 523-0124
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY:6CENSUS: 6DATE:
09/13/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kash Kaur/ Elaine TriteanTIME COMPLETED:
12:00 PM
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the case management visit conducted on 08/17/2021 .

LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiencies cited on 08/17/2021 have been cleared.

Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date.

Facility was provided POC cleared letter.

Exit interview conducted and a copy of this report emailed.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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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