<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502700869
Report Date:
08/26/2024
Date Signed:
08/26/2024 12:07:43 PM
Document Has Been Signed on
08/26/2024 12:07 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:
33
DATE:
08/26/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
11:15 AM
MET WITH:
Executive Director Jennifer Whiteley
TIME COMPLETED:
12:15 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
Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a Case Management visit. LPA Lund met with Executive Director Jennifer Whiteley and explained the reason for the visit. Census:33
LPA Lund received a 30- day notice for Resident (R1). The facility is working with the public guardian ship to see to if they can get R1 conservatorship. The facility will keep LPA Lund on updated on any changes.
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:
08/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1