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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700977
Report Date: 03/04/2025
Date Signed: 03/05/2025 12:10:46 PM

Document Has Been Signed on 03/05/2025 12:10 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MONTCLAIR HOMEFACILITY NUMBER:
502700977
ADMINISTRATOR/
DIRECTOR:		KALU, EKE PATRICKFACILITY TYPE:
735
ADDRESS:1413 MONTCLAIR DRIVETELEPHONE:
(925) 998-1037
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 4CENSUS: 4DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:caregiver Dolly Nnanna TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a one year annual/required visit. LPA spoke with Administrator Ester Kalu over the phone and explained the purpose of the visit. Administrator Ester Kalu gave permission for caregiver Dolly Nnanna to sign required paperwork. Census 4

LPA Lund & caregiver Dolly Nnanna toured/inspected the facility. LPA inspected the dining area, living area, and all other areas for client use. LPA observed to be furnished and maintained in compliance at this time.

LPA Lund inspected the (4) private resident bedrooms, furnishings for the residents were observed to meet the needs of the residents at this time. The Facility also had an office for staff. The facility also had three restrooms of which one was in the master bedroom. The contains a sufficient supply of towels and linens able to meet the needs of the clients at this time.

The Facility Medication closet (locked) where medication is stored. First aid kit was observed in the medication closet to be present and contained all required components at this time.

A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. The facility has two fire extinguisher that expire on 3/1/2024 and had a working telephone. LPA reviewed two staff & two clients files and were in compliance.
No deficiencies during today’s visit. Exit interview held and a report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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