502700934-6-14-2024-27-AS-RCAL-D68LTB-20240614090200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700934
Report Date: 05/15/2024
Date Signed: 06/14/2024 09:02:34 AM

Document Has Been Signed on 06/14/2024 09:02 AM - 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 MODESTO		FACILITY NUMBER:	502700934
ADMINISTRATOR:	JALILIE, MARILYN		FACILITY TYPE:	740
ADDRESS:	670 PARADISE RD		TELEPHONE:	6507408043
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY:	15	CENSUS: 3	DATE:	05/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jaime Velasquexo		TIME COMPLETED:	02:00 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 05/15/2024, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct an annual inspection. LPA Campbell was greeted by caregivers Jaime Timoli Velasquez and Cecilia Abieras. Both of whom were cleared to work in the facility. LPA Campbell stated the purpose of the vist and conducted a tour of the facility. The building is a single floor structure that is licensed for 13 residents. Currently, there are 3 clients in residence and 2 live-in staff. When asked, Caregiver Jaime Velasquez stated this was because it had been difficult to gain appropriate residents. The administrator for the facility is Michelle Jangar. The certificate number is #7002269740 and it expires on 10/25/2025 When LPA Campbell entered the facility, one resident was observed watching TV. Caregiver Timoli guided LPA Campbell to a hallway with empty bedrooms that had been closed off from the rest of the house. At the end of the hallway was a fire extinguisher last checked on 10/08/2023 and a fire exit. When LPA Campbell attempted to open the fire exit door, it would not open. LPA Campbell asked why the door could not be opened. Caregiver Timoli stated that a stick had been used to block the door due to the presence of homeless at the door at night. However, the stick had been placed outside of the door where anyone could remove it and staff confirmed the door worked. The occupied residential hallway was toured. Three bedrooms for three residents were observed with required furniture (bed, nightstand, closet, chair, lamp and drawers). LPA Campbell observed the staff hallway with two bedrooms and one bathroom with appropriate furnishings.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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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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: PROVIDENCE HOME OF MODESTO	FACILITY NUMBER: 502700934
	VISIT DATE: 05/15/2024

NARRATIVE

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The kitchen was examined by LPA Campbell. Sharps were under the sink and a magnet lock is used to make knives or other sharp objects inaccessible to residents. There were enough perishable foods to last staff and residents at least 2 days. Of the two refrigerators observed, both had a sign showing the required temperatures for the refrigerator and water. (Freezer < 0 degrees Fahrenheit, Refrigerator< 40 degrees Fahrenheit, Water = 105 to 120 degrees Fahrenheit). However, there was not a thermometer in the refrigerators and there was no log kept.

The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. A copy of this report has been emailed to the facility and the administrator was advised that a signed copy of this report shall be emailed to LPA.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 06/14/2024 09:02 AM - It Cannot Be Edited

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: PROVIDENCE HOME OF MODESTO	FACILITY NUMBER: 502700934
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	A fire exit was blocked. Based on observation, the licensee did not comply with the section cited above in 1 of 5 Fire Exits which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2024
	Plan of Correction
1 2 3 4	The facility corrected the deficiency by immediately by removing the obstruction from the door.

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.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 06/14/2024 09:02 AM - It Cannot Be Edited

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: PROVIDENCE HOME OF MODESTO	FACILITY NUMBER: 502700934
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(B)(1)

This requirement is not met as evidenced by: LPA Campbell observed no thermometers in the refrigerators or freezer and could not verify the termperatrures in the refrigerators..
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 2 freezers and 2 out of 2 refrigerators which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/16/2024
	Plan of Correction
1 2 3 4	The admnistrator will purchase 3 additional thermometers for the facility refrigerators within 24 hrs and will then email LPA Campbell images of their placement in the refrigerators to renee.campbell@dss.ca.gov.

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.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC809 (FAS) - (06/04)

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