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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502700869
Report Date:
04/18/2024
Date Signed:
04/18/2024 03:12:56 PM
Document Has Been Signed on
04/18/2024 03:12 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:
ORANGEBURG MANOR
FACILITY NUMBER:
502700869
ADMINISTRATOR:
ARBIOS, MARIE
FACILITY TYPE:
740
ADDRESS:
1248 NELSON AVENUE
TELEPHONE:
(209) 527-2222
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95350
CAPACITY:
90
CENSUS:
38
DATE:
04/18/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
03:00 PM
MET WITH:
Executive Director Jennifer Whiteley
TIME COMPLETED:
03:30 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 Executive Director Jennifer Whiteley and explained the reason for the visit.
LPA Lund received proper POC documentation for the deficiency citied on 4/3/2024.
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:
04/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/18/2024
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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