502700553-6-16-2025-27-AS-ELIM-DHQ3JE-20250616181726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700553
Report Date: 06/16/2025
Date Signed: 06/16/2025 06:17:48 PM

Document Has Been Signed on 06/16/2025 06:17 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:	EDITHS HOME CARE		FACILITY NUMBER:	502700553
ADMINISTRATOR/ DIRECTOR:	ARELLANO, EDITH		FACILITY TYPE:	740
ADDRESS:	3536 HALLSBORO CT		TELEPHONE:	(209) 567-2423
CITY:	MODESTO	STATE: CA	ZIP CODE:	95357
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	06/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:32 PM
MET WITH:	Edith Arellano, Administrator/Licensee		TIME VISIT/ INSPECTION COMPLETED:	06:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/16/2025 at 1:30 PM, Licensing Program Analyst (LPA) Triel Ellen LIndstrom arrived at the facility unannounced to conduct a required annual inspection and was greeted by Licensee/Administrator Edith Rodriguez (#7013119740). The LPA identified herself and explained the purpose of the visit. Licensee accompanied the LPA on a tour of the physical plant, including inside and outside areas, to ensure that there were no health and safety hazards. This facility is a residential home with four bedrooms. At the time of this site visit, the census was four residents. All four residents are non-ambulatory, although one resident can walk around with a walker. A Caregiver arrived at the facility at 1:40 PM. The second administrator of the facility Samuel Rodriguez (#6067581740) arrived at the facility at 2:30 PM. The LPA entered the facility and observed the required postings on a bulletin board to the right of the entry door, including personal rights, mandated reporting, emergency plan, ombudsman information, facility license, and the administrators' certificates. The LPA toured the living/dining room and observed five recliners, a television, and several side tables. There were two residents sitting in recliners in the living room; one was asleep. LPA also observed a dining table with four chairs.The fire extinguisher hung from the wall between the living room and kitchen and was last serviced in October 2024 by ARF Fire Extinguisher Co.of Modesto.

Lisa Rios	TELEPHONE: (916) 969-9685
Ellen Lindstrom	TELEPHONE: (916) 809-2109
	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EDITHS HOME CARE	FACILITY NUMBER: 502700553
	VISIT DATE: 06/16/2025

NARRATIVE

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The LPA toured the four bedrooms and observed the required furniture in good repair, including beds, dressers, night stands, chairs, and lamps. The bedroom that is presently occupied by two residents has a private bathroom that contained non-slip flooring, grab bars, a toilet chair and a shower chair. The water temperature was 111 degrees Fahrenheit.

The LPA toured a second bathroom in the hallway. This bathroom also contained non-slip flooring, grab bars, and shower and toilet chairs. The LPA observed a carbon monoxide detector in the hallway and a smoke detector in the living room and hallway. The Licensee tested the detectors and the alarm sounded.

The LPA toured the garage, which was accessed by a door at the end of the hallway. The garage contained a water heater and staff belongings. The garage is not accessed by residents.

The LPA toured a second living room that runs the length of the building. This room contained the washer and dryer. Laundry soap and other cleaners were stored in locked sheds in the back yard.

The LPA toured the backyard. The yard contained three locked sheds used to store disposable briefs and cleaning supplies. Both side gates are self-closing and latching. There is a paved shaded area with enough furniture for residents and their families.

The LPA toured the kitchen and observed a small dining room table with three chairs. The residents eat here and at the larger dining room table. The central medication storage is located in a locked pantry in the kitchen. It contained residents' medication in separate storage containers. All medication was in their original containers with labels intact. The LPA observed the first aid kit, which contained the required elements.

The LPA observed that the facility's paper-based Medication Administration Record was missing. The Administrator stated that she left it somewhere else yesterday and did not record yesterday PM or today AM medication administration.

The LPA reviewed the staff and resident records and found them complete. All staff has a criminal background clearance recorded in Guardian and valid first aid certificates.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Ellen Lindstrom	TELEPHONE: (916) 809-2109
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EDITHS HOME CARE	FACILITY NUMBER: 502700553
	VISIT DATE: 06/16/2025

NARRATIVE

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The LPA requested that updated copies of these documents be submitted to the Department by 5:00 PM on 06/23/2025:

(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(3) LIC 610 Current Emergency Disaster Plan
(4) Proof of Current Liability Insurance
(5) LIC 500 Current Personnel Report
(6) LIC 309 Administrative Organization

As a result of this annual visit, one deficiency was cited (see LIC809-D). The facility is not in compliance
with Title 22 Regulation. An exit interview was conducted with the Licensee/Administrator and a copy of the LIC 809, LIC 809-D, and appeal rights were provided to the facility.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Ellen Lindstrom	TELEPHONE: (916) 809-2109
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/16/2025 06:17 PM - It Cannot Be Edited

Created By: Ellen Lindstrom On 06/16/2025 at 06:00 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EDITHS HOME CARE	FACILITY NUMBER: 502700553
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(3)

Incidental Medical and Dental Care Services: A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on a review of medication records and interview with the Administrator/Licensee, the licensee did not comply with the section cited above as the facility's Medication Administration Record (MAR) was not on site at the time of the site visit. Medication administration was not recorded on 6/15/2025 PM and 6/16/2025 AM, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2025
	Plan of Correction
1 2 3 4	Licensee will send a photograph of the facility's MAR when it is back at the facility. Licensee created additional MAR forms during the site visit to use until the MAR returns to the facility.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (916) 969-9685

	Ellen Lindstrom
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (916) 809-2109

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC809 (FAS) - (06/04)

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