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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700934
Report Date: 01/26/2023
Date Signed: 01/31/2023 10:29:23 AM


Document Has Been Signed on 01/31/2023 10:29 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:
01/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jaime Velasquez and Cecelia AbierosTIME COMPLETED:
03:00 PM
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Unannounced case management visit made out to this facility on 01/26/2023 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Viarella who were met by the facility live-in caregivers, Jaime Velasquez and Cecelia Abieros, who were briefly interviewed.
This LPA requested that facility personnel go ahead and contact the facility designated Administrator, Michelle Jangar, to inform her that CCL was present at this time. Phone call was taken and this LPA did have a brief conversation with the facility designated Administrator at this time. It was discussed that the caregiver who was present, Jaime Velasquez, was able to accept and sign all forms and documents from Licensing for today's visit.
The purpose of this visit was to relay to this facility that the following had to be included in the eviction notices that were going to be given to the current residents:
  1. The Regional Office is inaccurate, it lists Fresno not Sac South.
  2. A current care plan should accompany the notice.
  3. Relocation Evaluation
  4. Based on the current service plan, the facility is responsible to prepare a relocation evaluation for each resident including recommendations on the type of facility that would meet the needs of the resident; and a listing of facilities, within a 60-mile radius of the closing facility, that meet the resident’s needs. (HSC 1569.682(a)(1))
  5. The facility must meet with the resident and his/her legal representative to discuss the relocation evaluation within 30 days of issuing the eviction notice. (HSC 1569.682(a)(3))
  6. The facility shall not accept new residents or enter into new admission agreements after it has issued the written notice of eviction. (HSC 1569.682(a),(b))
There were no deficiencies observed or cited during today's case management visit.
Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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