502700934-5-2-2023-27-AS-LKIG-CRFPKX-20230502112353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700934
Report Date: 05/01/2023
Date Signed: 05/02/2023 11:24:28 AM

Document Has Been Signed on 05/02/2023 11:24 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 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:	05/01/2023
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Warren Delfin, Licensee		TIME COMPLETED:	11:21 AM

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	A Non-Compliance office meeting was conducted today in the Santa Rosa Regional Office via Microsoft Teams. Present in the meeting were acting Regional Manager Stephenie Doub, Licensing Program Manager Kimberley Mota, Licensing Program Manager Liza King, Auditor Diana Chapman, Audit Manager Jacqueline Juarez, Licensing Program Analyst Araceli Canela, Licensee Warren Delfin, Facility Administrator Michelle Jangar, Facility Administrator Renato Yamat, and Facility finance staff Maximina "Ami" Landicho. This Non-Compliance Plan Conference is being conducted to discuss concerns identified by the Licensing Agency in regard to the findings of a recent solvency Audit that was conducted for the following facilities Providence Home of Aragon #486803945; Providence Home of Fairfield #486803888; Providence Home of Hillview #486803890; Providence Home of Vallejo #486803850 and Providence Home of Modesto #50270093 owned and/or operated by Warren Delfin. The financial audit documents showed the licensee does not have a sound financial plan and has negative equity. The facility is generating enough income to meet its expenses; However, expenses are not being paid; the amount of money being sent out of the facility account is negatively affecting the licensee’s solvency. Licensee is not managing finances of the facility in a manner that ensures solvency and there is a lack of control over the finances. Operating expenses were reviewed for Bank statements and cash reserves; Utilities; Rent; and Food. The licensee did not pay operational expenses timely. In Addition, there are tax liens against the facility. Continue report see LIC809-C

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

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

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: 05/01/2023

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
26
27
28
29
30
31
32

Facility was placed on a compliance plan for 1 year. Licensee has been advised that failure to complete the agreed upon actions by the dates given, will result in this Department taking the following action(s):

Facility agrees to provide quarterly financial documents for the month of May/June/July 2023; by August 18,2023. Records for the month of August/September/October 2023 by November 17,2023. Records for November/December 2023 and January of 2024 by February 16, 2024, and
February/March/April 2024 by May 17, 2024.

Facility agrees to ensure proper bookkeeping and having adequate Finance staff and not commingle funds between all five (5) licensed facilities.

Facility agrees to submit copies of proper 60-day resident eviction notices regarding Providence Home of Modesto #50270093 by May 5, 2023.

Facility to ensure food costs are related to the resident census per facility. Failure to comply with the terms and conditions of the one-year compliance plan may result in administrative action. Facility is subject to increased quarterly monitoring to ensure compliance.

Licensee was provided the following regulations:
CCR, Title 22, Division 6, Chapter 8, Section 87213, Finances
CCR, Title 22, Division 6, Chapter 8, Section 87205, Accountability
CCR, Title 22, Division 6, Chapter 8, Section 87555, General Food Service Requirement
CCR, Title 22, Division 6, Chapter 8, Section 87405, Administrator Qualifications and Duties

No citations were issued at this time. LPA will review and issue citations that may be warranted. A copy of this report was emailed to Administrator/Licensee, signature in file.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2