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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701083
Report Date: 08/27/2021
Date Signed: 08/27/2021 12:00:19 PM

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:DIGNITY SENIOR LIVING LLCFACILITY NUMBER:
502701083
ADMINISTRATOR:STANCU, COSMINAFACILITY TYPE:
740
ADDRESS:3100 RUSH CTTELEPHONE:
(209) 281-5151
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 0DATE:
08/27/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cosmina StancuTIME COMPLETED:
12:30 PM
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On 8/27/2021 Licensing Program Analyst LPA Ashley Boothe arrived announced to conduct a Prelicensing Inspection. LPA arrived at 9:00am and met with Administrator Cosmina Stancu with and stated the purpose of today’s visit. This facility has received a fire clearance on 7/19/2021 for 5 non ambulatory and 1 bedridden residents. Current Census 0. Current Administrator Certificate expires 9/30/2021.

The physical plant was toured inside and outside to ensure the safety of the residents. LPA's observed common area, kitchen, dining room, bedrooms, restrooms, garage, and backyard. The facility was found to be clean and in good repair in all areas. LPA observed the areas to store centrally stored medications, knives, cleaning supplies, and staff office to be locked and inaccessible to residents. The temperature inside the facility was measured at 74*F which is within the required range of 68 *F and 85 *F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 111.7*F which is not less than 105 *F and not more than 120 *F. The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed newly purchased fire extinguisher, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.

LPA completed Comp III with during visit.

The facility is ready for licensure and the applications unit will be notified of this visit and report. Exit interview and copy of report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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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