502700934-6-18-2022-27-AS-JLUD-CFHSRJ-20220618140625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700934
Report Date: 06/18/2022
Date Signed: 06/18/2022 02:06:35 PM

Document Has Been Signed on 06/18/2022 02:06 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
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: 3	DATE:	06/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Staff Jaime Velesquez		TIME COMPLETED:	02:30 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	LPA Jason Lund arrived at the above facility unannounced to conduct a post-licensing and an annual/required visit. LPA Lund was met by care staff Staff Jaime Velesquez and explained the reason for the visit. LPA Lund spoke with Administrator, Marilyn Jalilae and explained the reason for the visit. Administrator, Marilyn Jalilae gave permission for Staff Jaime Velesquez to help LPA Lund conducted the visits and sign required paperwork. Current census three 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.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2022

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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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: 06/18/2022

NARRATIVE

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Resident restrooms were toured. Grab bars and non- skid mats/surfaces were observed to be present and in good repair at this time. Linen closet was observed to contain all of the necessary components sufficient to meet the needs of the residents at this time. LPA Observed that the Air Conditioning was not working in the Residents rooms and the Air Conditioner is not currently working in the Residents rooms.

Fire extinguishers and carbon monoxide detectors were observed to have been annually serviced by the local fire authority on 11/10/2022 and in compliance at this time.

Facility office area was toured. 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.

As a result of this visit, see deficiencies cited, per Title 22 Regulations, Division 6. Exit interview conducted, appeals rights provided.

Exit Interview with Staff Jaime Velesquez and Administrator, Marilyn Jalilae over the phone and report left.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/18/2022 02:06 PM - 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PROVIDENCE HOME OF MODESTO	FACILITY NUMBER: 502700934
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(b)(2)

This requirement is not met as evidenced by: LPA Lund observed the Air Conditioner (AC) to be out of order in the residents rooms. The only AC working is in the TV area.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2022
	Plan of Correction
1 2 3 4	The Facility will get the AC fixed

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2022

LIC809 (FAS) - (06/04)

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