502701044-5-2-2023-27-AS-APAA-CRFL2F-20230502082217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701044
Report Date: 05/01/2023
Date Signed: 05/02/2023 08:22:45 AM

Document Has Been Signed on 05/02/2023 08:22 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:	ANGEL'S CARING HAND		FACILITY NUMBER:	502701044
ADMINISTRATOR:	ANTONIO, MA TABITHA		FACILITY TYPE:	740
ADDRESS:	3709 COYE OAK DR		TELEPHONE:	(209) 312-9880
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 5	DATE:	05/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Maria Angelica Souxouay		TIME COMPLETED:	02:30 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	On 05/01/2023 at 11:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by staff member, Dodie Aguilucho and explained the purpose of the visit. LPA asked for SM Aguilucho to contact the Facility Designated Administrator to inform them that CCL was present at this time. It was learned at this time that FDA Antonio was unable to meet the LPA at this time. Shortly after, LPA met with Facility Designated Representative (FDR), Maria Angelica Souxouay. This facility is licensed to serve 6 residents, who all may be deemed non-ambulatory. This facility also has a dementia plan on file. Current census was 5. LPA reviewed 5 resident files and 2 staff files. All files were current and up to date. Facility Administrator has a current and active administrator certificate #6055145740 and expires on 01/27/2024. A tour of the facility was conducted. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Jorgenson Co on 02/28/2023. The kitchen area was toured. LPA observed a 7 day non-perishable and 2 perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage. LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ANGEL'S CARING HAND	FACILITY NUMBER: 502701044
	VISIT DATE: 05/01/2023

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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional perishable food supplies were identified.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

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

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability Insurance

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to the facility.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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