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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700934
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:57:29 AM


Document Has Been Signed on 06/23/2022 11:57 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PROVIDENCE HOME OF MODESTOFACILITY NUMBER:
502700934
ADMINISTRATOR:JALILIE, MARILYNFACILITY TYPE:
740
ADDRESS:670 PARADISE RDTELEPHONE:
(650) 740-8043
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:15CENSUS: 3DATE:
06/23/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Staff Jaime Velesquez TIME COMPLETED:
12:00 PM
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LPA Jason Lund arrived at the above facility unannounced to conduct a proof of correction (POC) visit. LPA Lund was met by care staff Staff Jaime Velesquez and explained the reason for the visit. LPA Lund spoke with Administrator, Michelle Jangar and explained the reason for the visit. Current census three.

LPA toured the facility and the three residents’ rooms (Eight through twelve) Air Conditioner is working in the three residents’ rooms and is currently at 75 degrees. The facility is waiting for parts for the rooms one through seven.

No Deficiencies cited at this time.
Exit Interview with Staff Jaime Velesquez and Administrator, Michelle Jangar over the phone and report left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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