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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701119
Report Date: 03/07/2022
Date Signed: 03/07/2022 04:02:05 PM


Document Has Been Signed on 03/07/2022 04:02 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:ELEGANT CARE ASSISTED LIVING FACILITYFACILITY NUMBER:
502701119
ADMINISTRATOR:BHINDER, JAGTAR SFACILITY TYPE:
740
ADDRESS:2108 DOS PASSOS WAYTELEPHONE:
(209) 665-5121
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 0DATE:
03/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:J. BhinderTIME COMPLETED:
04:13 PM
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LPA Albert Johnson arrived announced at the facility and was met by J. Bhinder.

The following items were corrected as requested by LPA Hurt.

Resident bedrooms have 8 cubic feet of storage space and the
Facility has an adequate food supply of 7-day non-perishable and 2 day perishables food. (Photos taken)

The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Unit.

Applicant was reminded of the statute that requires notification to Licensing Program Analyst within 5 business days of admitting the first resident. This notification may be done by phone, mail, email or fax.

An exit interview was conducted and a copy of this report was provided at the time of visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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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