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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700934
Report Date: 12/12/2022
Date Signed: 12/13/2022 09:55:19 AM


Document Has Been Signed on 12/13/2022 09:55 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:
12/12/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jaime VelasquezTIME COMPLETED:
03:00 PM
NARRATIVE
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Unannounced case management visit made out to this facility on 12/12/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the live-in caregivers, Jaime Velasquez and Cecilia Abieras, who were briefly interviewed at this time. Also present was another female third party contractor.
Current census was (3) residents.
The purpose of this visit was to conduct a Health and Safety check on the facility and current residents at this time.
This LPA requested that the caregivers go ahead and contact the facility designated Administrator, Michelle Jangar, to inform her that CCL was present at this time. A brief conversation was held with Jangar at this time.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

This facility was cited and civil penalties were issued in the amount of $500 at this time per the LIC 421BG.

Appeal rights were printed and a copy was given to the facility staff person Velasquez at this time.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/13/2022 09:55 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
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: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2022
Section Cited

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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or:
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Facility designated staff person stated that this individual who was not properly fingerprint cleared and associated to this facility must be removed immediately from the premises. A statement of removal will be completed and submitted into CCL by the due date. This individual will not be allowed back into this facility until the proper fingerprint clearance
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This facility was deficient as evidenced by the presence of an individual who was not properly fingerprint cleared and associated to this facility at the time of this LPA's visit. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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has been attained with proper association.

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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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