502700934-6-27-2023-27-AS-CYAG-CT7PPW-20230627113014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700934
Report Date: 06/21/2023
Date Signed: 06/27/2023 11:30:23 AM

Document Has Been Signed on 06/27/2023 11:30 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
SACRAMENTO AC/SC, 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:	06/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jaime Velasquez		TIME COMPLETED:	01:00 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	Unannounced annual visit made out to this facility on 06/21/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility live-in caregiver, Jaime Velasquez, who was briefly interviewed at this time. This LPA requested that the facility caregiver go ahead and contact the facility designated Administrator, Michelle Jangar, to inform her that CCL was present at this time. It was learned that the facility designated Administrator stated that she would take her at least (2) hours before she would be able to attend the annual visit with this LPA today. It was decided that all forms and documents would be signed and received by the facility live-in caregiver, Jaime Velasquez, in lieu of the facility designated Administrator. Current census was 3 residents. It was learned that there weren't any residents under the care of home health at this time. There weren't any residents under the care of hospice at this time. Tour of this facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed. Drawers and cabinets housing cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Dining room, living area, and all other areas designated for resident use were observed to be maintained and observed to be in compliance at this time. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be present and maintained in compliance at this time. A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in compliance at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Medication cabinet, located as a medication unit in the dining area, was reviewed. Policies and procedures for dispensing, handling, and overall documentation of the resident medications were discussed with the facility live-in caregiver at this time.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PROVIDENCE HOME OF MODESTO	FACILITY NUMBER: 502700934
	VISIT DATE: 06/21/2023

NARRATIVE

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Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities. Additional food storage units were observed to be present in the staff living quarters.
Fire extinguishers were observed to be placed throughout this facility and were annually inspected on 11/08/2022 by the local fire equipment company, Cal-State Fire Extinguisher Company, and in compliance at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Linen closet, located in facility hallway, was observed to contain a sufficient supply of blankets, sheets, and towels for resident use.
Laundry area, located next to the dining room, was observed to be locked and made inaccessible to the residents at this time.
Exterior grounds of this facility was toured. Facility perimeter fence, side gate, and emergency exits were reviewed.
Additional shed in the backyard was reviewed and observed to be locked and made inaccessible to the residents at this time.
Additional housing unit was observed to be locked and used solely for storage by the Licensee.

The following forms were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

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

Appeal rights were printed and reviewed with the facility live-in caregiver, Jaime Velasquez, and a copy was given to him as well.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/27/2023 11:30 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
SACRAMENTO AC/SC, 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: 06/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in [2] out of [2] water taps delivering hot water were measured at 130.2 degrees well above the allowed range of 105-120 degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2023
	Plan of Correction
1 2 3 4	The facility designated representative stated that all of the faucets and sinks will be reviewed to make sure that the hot water being delivered for use by the residents are within the allowed range of 105-120 degrees at all times. A statement of correction, along with readings of the hot water temperatures for a 24 hour period, will be completed and submitted into CCL by the due date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/27/2023 11:30 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
SACRAMENTO AC/SC, 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: 06/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that several window screens had holes, rips, and tears in them which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	The facility designated representative stated that all of the window screens will be reviewed to make sure that they do not possess any holes, rips, or tears at all times. A statement of correction, along with photos of the replaced/repaired window screens, will be completed and submitted into CCL by the due date

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [3] facility personnel files were incomplete missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	The facility designated representative stated that all of the facility personnel files will be audited and updated to contain all of the required forms and documents at all times. A statement of correction, along with copies of the updated personnel files, will be completed and submitted into CCL by the due date

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 06/27/2023 11:30 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
SACRAMENTO AC/SC, 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: 06/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(d)

Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [1] out of [3] facility personnel files did not contain the required initial/ongoing on the job training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	The facility designated representative stated that all of the facility personnel files will be updated for all staff to receive the required initial/ongoing on the job training. A statement of correction, along with documentation of the initial/ongoing training hours, will be completed and submitted into CCL by the due date

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC809 (FAS) - (06/04)

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