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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701015
Report Date: 06/09/2022
Date Signed: 06/09/2022 03:29:26 PM

Document Has Been Signed on 06/09/2022 03:29 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:COMFORT CARE LIVINGFACILITY NUMBER:
502701015
ADMINISTRATOR:GORDON, GREGORYFACILITY TYPE:
735
ADDRESS:808 MCHENRY AVETELEPHONE:
(209) 524-0808
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 120CENSUS: 0DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Gregory GordonTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jason Lund conducted a annual/required visit. LPA met with Gregory Gordon and explained the reason for the visit. Current Census 0

During today visit the LPA Lund, Gregory toured the physical plant. We walked facility including but not limited to the kitchen, residents’ rooms, resident bathrooms, activity rooms, dining room, and courtyard/perimeter. LPA observed that the rooms are equipped with the required furniture and sufficient lighting throughout the facility. There are no bodies of water present in the facility at this time. Fire extinguishers, smoke detectors, and carbon monoxide detectors were observed in the facility and current. While touring the facility, the LPA observed medication room locked.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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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