502701083-8-30-2023-27-AS-APAA-CV7KBS-20230830074559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701083
Report Date: 08/28/2023
Date Signed: 08/30/2023 07:46:07 AM

Document Has Been Signed on 08/30/2023 07:46 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:	DIGNITY SENIOR LIVING LLC		FACILITY NUMBER:	502701083
ADMINISTRATOR:	STANCU, COSMINA		FACILITY TYPE:	740
ADDRESS:	3100 RUSH CT		TELEPHONE:	(209) 281-5151
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 4	DATE:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Cosmina Stancu		TIME COMPLETED:	03:00 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 08/28/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by Licensee, Cosmina Stancu and explained the purpose of the visit. This facility is licensed to serve and accept up to 6 residents who are deemed to be non-ambulatory only. This facility has a dementia plan on file and a hospice waiver for 2. LPA reviewed 4 resident files. It was learned that 1 out 4 residents were receiving hospice services at this time. 4 out 4 resident files were current and up to date. LPA reviewed 4 staff files. 4 out 4 staff files were current and up to date. A tour of the facility was conducted. Fire extinguisher located in the kitchen was inspected by a located Fire company, Assured, and was inspected on 08/15/2023. 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

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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: DIGNITY SENIOR LIVING LLC	FACILITY NUMBER: 502701083
	VISIT DATE: 08/28/2023

NARRATIVE

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The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610
-Liability Insurance

Technical Assistance was provided for the Section, 87465(h)(5).

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 Licensee, Cosmina Stancu.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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