502700934-6-23-2021-27-AS-CYAG-C49SK6-20210623135609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700934
Report Date: 06/23/2021
Date Signed: 06/23/2021 01:56:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	PROVIDENCE HOME OF MODESTO		FACILITY NUMBER:	502700934
ADMINISTRATOR:	JALILIE, MARILYN		FACILITY TYPE:	740
ADDRESS:	670 PARADISE RD.		TELEPHONE:	(650) 740-8043
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY:	15	CENSUS: 0	DATE:	06/23/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Michelle Jangar and Marilyn Jalilae		TIME COMPLETED:	12:30 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	Announced Prelicensing visit was made out to this facility on 06/23/2021 by LPA Yang. This LPA was met by the Applicant, Michelle Jangar, and the facility designated Administrator Marilyn Jalilae who were briefly interviewed. This Applicant is seeking licensure for a 15 bed RCFE of which (2) residents are Ambulatory, (9) Non Ambulatory and (4) Bedridden at any given time. Current census was zero residents. Tour of the facility was conducted. Kitchen area was toured. Cabinets and drawers were observed to be in good repair and contained all required dishes, cook ware, and flatware sufficient to meet the needs of the residents at this time. Cabinets storing knives and cleaning agents were observed to be locked and made inaccessible to the residents at this time. It was observed that there was a gate that latched separating the kitchen area from the common dining area. Food storage units were reviewed and observed to be set at the proper temperatures for the refrigerator and freezer components. Common areas were toured such as the living room, dining room, and all other areas intended for resident use. Furniture and furnishings were observed to be in good repair and able to meet the needs of the residents at this time. A tour of the resident bedrooms was conducted. it was observed that resident bedrooms were furnished and maintained to meet the needs of the residents at this time. Resident restrooms were toured. Grab bars and non skid mats/surfaces were observed to be present and in good repair at this time. The hot water was measured to make sure that it was within the allowed range of 105-120 degrees. Linen closet was observed to contain all of the necessary components sufficient to meet the needs of the residents at this time. Fire extinguishers and carbon monoxide detectors were observed to have been annually serviced by the local fire authority on 11/11/2020 and in compliance at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PROVIDENCE HOME OF MODESTO	FACILITY NUMBER: 502700934
	VISIT DATE: 06/23/2021

NARRATIVE

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Facility office area was toured. Resident files, staff files, and medications were observed to be maintained in compliance at this time. Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
First aid kit was observed to be present and contained all necessary components at this time.
Laundry area was toured. It was observed that all cleaning agents, detergents, and supplies were locked and made inaccessible to the residents at this time.
A tour of the exterior grounds was conducted. A review of the perimeter fence, side gates, and exterior exits were conducted and observed to be in good repair at this time.

This Applicant, Michelle Jangar, will be waived for the Component III since she has already undergone this portion of the licensing process for a previous facility that was licensed.

This facility has been observed to be in compliance at this time. This application will be forwarded for further processing with the Central Applications Bureau (CAB).

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

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