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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700934
Report Date: 11/01/2024
Date Signed: 11/01/2024 12:42:18 PM

Document Has Been Signed on 11/01/2024 12:42 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:PROVIDENCE HOME OF MODESTOFACILITY NUMBER:
502700934
ADMINISTRATOR/
DIRECTOR:		JALILIE, MARILYNFACILITY TYPE:
740
ADDRESS:670 PARADISE RDTELEPHONE:
(650) 740-8043
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 15CENSUS: DATE:
11/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Michell Jangar, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 11/01/2024, Licensing Program Analyst Renee Campbell arrived at the facility announced to meet with the licensee, Michell Jangar for a forfeiture of the facility license. The license is being forfeited due to a change of use. A 60 day notice to evict residents due to change of use was submitted on January 24, 2024. The two residents left the week of 10/15/2024 and all belongings were removed as of 10/15/2024.

Two people will remain living at the facility: Jaime Velasquez and Cecilia Abierras. Both were staff who had been associated to Providence Home of Modesto since 03/29/2022 and both provided ID’s as verification of identity. Both staff have also been cleared as shown on Guardian.

LPA Campbell conducted a walk-through of the facility and verified that no residents were currently living in the facility. Future correspondence may be directed to : Michell Jangar, at 851 Burlway Rd., Suite 216, Burlingame, CA 94010

The license was surrendered to LPA Campbell on this date. Exit interview completed. Signed copies of the report were left at the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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