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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502700517
Report Date:
06/06/2024
Date Signed:
06/06/2024 12:06:27 PM
Document Has Been Signed on
06/06/2024 12:06 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:
KIND CARE HOME II
FACILITY NUMBER:
502700517
ADMINISTRATOR:
KAHLON, HARDEEP
FACILITY TYPE:
740
ADDRESS:
1020 JAYHAWK WAY
TELEPHONE:
(209) 523-0124
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95358
CAPACITY:
6
CENSUS:
5
DATE:
06/06/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
10:45 AM
MET WITH:
Care Staff Yolanda Shannon
TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a proof of correction (POC) visit. LPA Lund met with care staff Yolanda Shannon and explained the reason for the visit. Administrator Kashminder Kaur could not make the visit today and gave permission for Care Staff Yolanda Shannon to sign required paperwork.
LPA Lund received proper POC documentation for the deficiency cited on 4/24/2024.
No deficiencies were observed and cited during this visit.
Exit interview conducted and report left.
SUPERVISOR'S NAME:
Lisa Rios
TELEPHONE:
(916) 969-9685
LICENSING EVALUATOR NAME:
Jason Lund
TELEPHONE:
(916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE:
06/06/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/06/2024
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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