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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701083
Report Date: 08/17/2022
Date Signed: 08/17/2022 02:56:57 PM


Document Has Been Signed on 08/17/2022 02:56 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: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: 2DATE:
08/17/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Cosmina StancuTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Arielle Pascua conducted an unannounced visit on this day for the purpose of conducting a Post Licensing Evaluation. LPA Pascua arrived and was greeted by Caregiver, Cynthia Miller. LPA Pascua asked Caregiver, Miller to contact the Facility Designated Administrator (FDA) to let them know that CCL was present at this time. FDA Cosmina Stancu arrived shortly after LPA Pascua's arrival.
This facility is licensed to serve and accept up to 6 residents who are deemed to be non-abulatory only. . Administrator holds a current certificate and expires on, 01/25/2023. Current Census was 2.
Tour of the facility was conducted.
Fire extinguisher located in the kitchen was purchased on 02/07/2022.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Food storage units were reviewed for adequate 2-day perishable and 7-day non perishable quantities at this time. Knives were locked and made inaccessible to the residents at this time.
LPA Pascua 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 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.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet resident needs at this time.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

A copy of this report was provided to the Facility Designated Administrator.

Exit Interview.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
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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